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ELEMENTS 



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THE THEORY AND PRACTICE 



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PHYSIC. 



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ELEMENTS 



THE THEORY AND PRACTICE 



OF 



PHYSIC, 



BY 



GEORGE GREGORY, M. D. 

I! 

WITH 



NOTES AND ADDITIONS. 

ADAPTED TO THE PRACTICE OF THE UiMTED STATES, 

BY 
NATHANIEL POTTER, 31. D. 

PROFESSOR OF THE PRACTICE iafl-PH*»JjB-4:X THE UNIVERSITY OF MARTLAXP, 



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ly MORBIS, Siy^ .^.^^IS, SIVE CHRONICTS, VIREX^>ClM(f UX dVlV, PER HUMAXAS 

spEcfelATfo^tSff ERE I'scoj'ivj^jAim.^RieHi^s/r^ — BAGLIVI. 



Jifr^IS, SIVE CHRONICTS, VIRF 
LTfoaftS^fERE INCO>rPRfJ«^ 




SECOND AMERICAN FROM THE THIRD LONDON EDITION, 

WITH >'UMEROUS ADDITIONS AND AMENDMENTS. , 

/ 

IN TWO VOLUMES. — WOs^sa^ ^/^ 
VOL. L *t->^-^^ / 

/ 

PHILADELPHL\ : 
TOWAR & IIOGAN 255, 3IARKET STREET. 

1829. 



Eastern District of Pennsylvania, to wit: 

Be it RE3tEMBERXD, That on the 9th day of January, in the fifty-third 
year of the Independence of the United States of America, A.D. 1829, Towar 
'& HooAX, of the said District, have deposited in this office the title of a book, 
the rig-ht whereof they claim as Proprietors in the words following-, to wit: 

''Elements of the TVieory and Practice of Physic, by George Gregory, 31. 1). 
with Notes and Mditions, adapted to the Practice of the United States, by 
Nathaniel Potter, M. D. Professor of the Practice of Physic in the University of 
Maryland, and S. Colhoun, M. D, * In morbis, sive acutis, sive chronicis, viget 
occultum quid, per humanas speculationes fere incomprehe?isibile.' — Baglivi. 
Second American from the Third London Edition, with numerous Mditions and 
Amendments. In Two Volumes." 

In conformity to the Act of the Congress of the United States, entitled " An 
act for the encourag-ement of learning-, by securing- the copies of maps, chai-ts, 
and books to the authors and proprietors of such copies during- the times 
therein mentioned;" and also to the Act entitled " An act supplementary to 
an act entitled ' An act for the encouragement of learning, by securing the 
copies of maps, charts, and books to the authors and proprietors of such 
copies, during the times therein mentioned,' and extending the benefits thereof 
to the arts of designing-, engraving, and etching historical and other prints." 

p. CALDWELL, 
Clerk of the Eastern District of Pennsylvania. 



CoM] 

///St 

Coll. 

.GS/ 



ADVERTISEMENT TO THE THIRD EDITION. 



In the year 1826, an Edition of this Work was published 
at Philadelphia, with very copious Notes and Additions by 
Dr. Potter, Professor of the Practice of Physic in the University 
of Maryland, and Dr. Colhoun of Philadelphia. In preparing 
the present edition for the press, the author has not neglected 
the opportunity thus offered him of enhancing its value. He 
desires to offer his testimony to the merits of the American 
Editors, who with great judgment have filled up parts of the 
w^ork which had been but briefly sketched ; and by their notice 
of many American drugs unknown to the Author, and by their 
greater familiarity with the diseases of warm climates, have 
added largely to its general utility. 

It would be superfluous to specify in detail the different 
chapters which have now undergone alteration. The whole 
has been thoroughly and carefully revised. Several topics, 
unnoticed in the preceding editions, have been introduced, 
such as Delirium tremens. Cachexia africana, Hepatalgia, 
Erythema nodosum, &c. Many have been considerably 
expanded; and throughout the work, the results of the author's 
recent experience will be found united with the most important 
practical suggestions of late writers. 

GEO. GREGORY. 

LoNDoy, Upper St. John's St. Golden Square, 
June 12, 1828. 



> . 



CONTENTS OF VOL. I. 



ACUTE DISEASES. 

Page 
Class I. Fevers, 43 

General Doctrine of Fever, 43 

Varieties and Symptoms of Continued Fever, 58 

Causes of Continued Fever, - - - 79 

Treatment of Continued Fever, 88 

Typhus Syncopalis, 115 

Of the Plague, 123 

Intermittent and Remittent Fevers, 132 

Ofthe Yellow Fever, 156 

Of the Miliary Fever, 178 

Class II. Thb Exanthemata, or Eruptive Fevers, - - - . 174 

The Exanthemata in General, 174 

Ofthe Small Pox, 196 

Chicken Pox, Cow Pox, and Modified Small Pox, - - - . 215 

Of the Measles, 227 

Of the Scarlet Fever, 237 

The Minor Exanthemata, 253 

{Herpes, Urticaria, Lichen, Roseola, Pemphigus and Pomjiholyx, Framboesia.) 
Class DI. Phlegmasia, or Inflammatory Diseases, - - - - 261 

General Doctrine of Inflammation, 261 

General Doctrine of Inflammation (continued), .... 273 

Chronic Inflammation, 285 

Local Inflammations, 290 

Phrenitis and Hydrocephalus, 325 

Ophthalmia, 344 

Catarrh, Sore Throat, and the Mumps, 367 

Inflammation of the Larynx and Trachea, 378 

Pneumonia, 392 

Pneumonia Biliosa, •412 

Subacute and Chronic Bronchitis, 415 

Peripneumonia Notha, 417 



CONTENTS. 

Page 

Consumption, 424 

Pericarditis, - _- - - 442 

Peritonaeal Inflammation, 449 

Inflammation of the Mucous Membrane of*the Alimentary Canal, - 457 

Dysentery, 465 

Hepatitis, '■■ 474 

Rheumatism, " 483 

Cruritis, or Phlegmasia dolens, 496 

Of the Gout, 498 

Eiysipelas, 511 

The Hemorrhoidal Fever, 515 

Class IV. H^mohbhagies, 517 

General Doctrine of Hsemorrhag-y, 517 

Anaemia, i'" " " " ^^^ 

Haemorrhagy from the Nose, - - - - ' - - - - 524 

Hsemorrhagy from the Lungs, 527 



PREFACE 



Any commendation of the following work would be almost 
superfluous. Its own intrinsic worth is its best eulogy; but it 
is only to those who are well versed in practical lore, that it 
will heviV 2^ri'ina facie evidence of its own superior excellence. 
The )"Oung and inexperienced^ cannot duly estimate a system 
which constitutes a rather converging series of maxims, than 
the minutiae of practical detail. The author seems to have 
composed it as a syllabus, from which he has left himself at 
liberty to expatiate in all the latitude which great erudition, 
faithful observation, and ample experience justify. If we 
were inclined to adopt a text-book, as a guide to a practical 
course, Gregory's Practice would claim a preference to all 
other works. 

The author has presented his work in the most interesting 
garb, by combining the etiology, pathology, and symptoma- 
tology, in the series of cause and effect. This scheme has been 
executed with so much felicity, in so small a compass, that it 
becomes a real treasure to both preceptor and pupil. The 
former finds his experience confirmed, and the latter has only 
to dig, to find a mine more precious than silver or gold. How 
many of our practical books are almost destitute of all the laws 
of pathology, are nearly empirical, and therefore in the exact 
ratio of their defect of principle, indifferent or useless ! — Nor 
are these the only merits of the work. We must bestow on 
the author his due meed of praise for disclaiming that fastidious 
adherence to nosological distinctions, to which we think so 
many of his countrymen unduly attached. We do not predicate 
this reflection on existing systems of nosology or on a convic- 
tion that a perfect synoptical arrangement of diseases will be 
2 



X PREFACE. 

« 

forever impracticable ; but from the belief, that all the systems 
hitherto proposed are erroneous, and perhaps radically wrong. 
We venture to predict, that no perfect, or even very useful 
system of nosology will ever be devised, unless it shall have 
been predicated upon the natural and obvious division of the 
human body, into various departments, according to their 
difference of organizations. The elective attraction of the 
causes of diseases for some textures in preference to others, as 
well as a natural preference of medicine for one organ rather 
than another, indicate the necessity of reverting to first prin- 
ciples, before we can construct nosological tables upon a 
philosophical basis. 

The learned and judicious author not only reasons well from 
just premises, deducing legitimate practical conclusions, but has 
broken some of the strongest habitual associations. He does 
not believe that the constitutions of the British people have so 
degenerated, that they cannot sustain the rigour of the anti- 
phlogistic treatment adopted and so triumphantly pursued by 
the immortal Sydenham. The sanguinary practice so familiar 
to us, would not alarm him, who well knows it is not debility, 
but disorganization that is to be apprehended in fevers and 
inflammations. This rotten excrescence of the Brunonian 
doctrine, had been already extirpated by his countrymen 
Mills, Armstrong, and some others. The most prominent 
feature in his character seems to be his judgment, or that 
gift of nature which confers on a few distinguished individuals 
the faculty of discriminating between the true and the false, 
almost intuitively, certainly without any tedious process of 

N. POTTER. 



INTRODUCTORY DISCOURSE 



On the nature of Medical Causes and Effects — Difficulty of ascertain- 
ing the causes of Medical Phenomena — Mode of investigating them 
— Remarks on two of Sir Isaac Newton's Rules of Philosophy, as 
they have been applied to Medicine — On Hypothesis — On Theory 
— On Invention — On Observation, the true means of cultivating 
Medicine — On some of the sources of error discovered in the history 
of Medicine — On the climate, modes of living, and diseases of the 
United States. 

The object of the science of medicine is the prevention and the cure 
of diseases. Though the noxious agents which surround us are numer- 
ous, yet nature supplies, in some measure, the means of preventing and 
curing their bad effects. Thus the exhalations from putrefying animal 
matter produce fever; and their disagreeable and horrible stench is a 
sufficient warning to avoid them : if fever has taken place from this 
cause, the delirium, and the morbid heat of skin which attend it, inspire 
an instinctive disposition to plunge into cold water; and the relief 
produced by it is immediate, and generally certain. 

The power of nature alone, though great, is not, however, always suf- 
ficient, either to discover these noxious agents, or to remove the diseases 
produced by them : thus the miasmata from vegetables, though equally 
baneful with those from animal matter, often give no warning by their 
smell, and destroy without their danger being anticipated. This is true 
with regard to many other noxious agents : thus sudden exposure to 
mephilic airs in descending below the surface of the earth, takes away 
life ; and no instinct, no sense, warn us of our danger. We there- 
fore require other aids than those of nature alone, in avoiding the 
causes of diseases ; and it is the province of the science of medicine 
to supply them, by a cautious examination of the properties of bodies 
around us. 



XU INTRODUCTORY DISCOURSE. 

Though diseases are often relieved without the assistance of art, yet \i 
is well known that niany processes undertaken by nature to repair any 
injury, are often too violent, and destroy life. Here then art assists; 
and in doing so, the properties and nature of the system, as also those of 
external bodies, must be studied, to discover their effects upon it. The 
mind and the senses, accordingly, are the instruments by which this end 
is efTected. In their application for the purposes of discovery to the 
world around us, great errors have been committed, and much useful 
time and labour has been lost, in their direction to the practical duties of 
our profession. 

In the following remarks, therefore, as medicine is a science which 
teaches something to be done, and the most correct mode of doing it, and 
as it uses natural agen(s to effect its purposes, we shall first consider the 
nature of cause and effect, in relation to the production and the cure of 
diseases ;and secondly, the sources of the errors of medicine, discovered 
in the history of its past ages. We shall thus be enabled to pursue our 
way upon the firm and open road opened by modern discovery, with 
profit and advantage. 

ON THE NATURE OF MEDICAL CAUSES AND EFFECTS. 

Our knowledge of external nature is derived from bodies, either at 
rest or in motion. Upon each of these stales, some remarks suggest 
themselves: first, with regard to the operations of the mind in receiving 
knowledge from bodies at rest. 

When v.'e look upon a mass of snow, the mind receives an impression, 
the result of the combined action of the particles of which this substance 
consists : it presents a white aggregate, which is cold, soft, Szc. ; into 
the idea of which enters simply a number of minute juxtaposed bodies. 
Regarded in this light, it is a whole, a mass totally distinct and separate 
from all other bodies around it.* The mind, however, can take other 
views ; for the mass of snow is composed of other substances, since it can 
be separated into oxygen and hydrogen ; two bodies possessing still dif- 
ferent properties : these again can be separated still farther into heat, 
light, and certain bases. 

In these views, the mind considers the snow, as perfectly at rest, and 
composed of a certain number of bodies, arranged with xcgard to each 
other in certain relations,t and each of these are grouped together in a 
defined series. The same is true of the anatomy of the human body. 
That science considers the various structures, as they lie with regard to 

* JBrown's Lectures on the Human Mind. I Ibid. 



INTRODUCTORY DISCOURSE- Xlll 

cacli Other, in the system ; and thus separates them, part after part ; and 
acquires a knowledge of their situation, and the mode in which they 
operate upon each other, when set in motion. 

The mind, therefore, though the subject it contemplates is entirely at 
rest, exerts a great modifying power over the knowledge it gains from 
without : for when we contemplate the mass of snow, we may either 
consider it simply as a collection of white particles: or we may go fur- 
ther, and regard these, as composed of other particles; these again oi 
other components.* At each step the body is considered as composed 
of a series of groups, each group being regarded as an individual, though 
its component parts are numerous, and have each very different quali- 
ties. The same is true in anatomy. The whole system, composed of a 
variety of different substances may be regarded as a whole; or may be 
analysed into bone, muscle, nerve, tendon, blood vessel, &c. : each of 
these may be considered as also composed of particular aggregates of 
matter; as the muscles are formed of fibres of a peculiar kind, of nerves 
and of blood-yessels ; these fibres, nerves, and blood-vessels are com- 
posed of other aggregates, till separating aggregate from aggregate, we 
arrive at the ultmiate result of which the science is capable. At each 
step, however, there are the same number of particles combined in the 
whole or in each group, but by the mind, they are differently viewed and 
assembled into masses. This disposition to analyze and separate bodies 
from each other, enlarges the range of our power, and it is by thus parting 
the groups of natural bodies from each other, that the power and effect 
of each, is appreciated, and our knowledge increased. It is, however, 
only an act of the mind, for the snow and the body are the same, whether 
considered as a mass, or as an assemblage of organs, or of particles 
composed of various ultimate atoms. It is one great principle of science, 
thus continually to oppose and counteract this disposition of the mind, 
to mass into groups, and to take too partial, or too general views of the 
various subjects of nature, and thus to discover by analysis, her various 
combinations ; chemistry in the decomposition of bodies — anatomy in 
the separation of the different parts of the human body, by the knife, 
consists in this simple process ; the same mode of investigation applies 
to the phenomena of disease, both in understanding their nature, and in 
curing them. 

1st. With regard to their production. If the substance, which gives 
hardness to the bones, be removed, they become flexible, the body by its 
weight crooks the limbs, and walking is performed with difficulty. The 
chest, which contains the lungs and the heart, presses upon these organs ; 

* Brown's Lectures on the Human Mind. 



XIV INTRODUCTORY DISCOURSE. 

the lungs do not dilate sufficiently, breathing is performed with difficulty, 
and the powers of life are impaired. 

If a bone be displaced at the joint, the natural and relative situation 
of the parts, of the muscles, the tendons, and the blood-vessels, are 
deranged, and the limb becomes useless. To understand exactly the 
state of the parts in these diseases, it was necessary, originally, in the 
first case to analyze the bones, to know that a certain substance, the 
phosphate of lime, was wanting, and to communicate this earth in greater 
quantities to the system, and by a proper mode of cure to fix it in that 
structure in which it is deficient : in the second case, to apply an 
apparatus, which may bring into play the power of the muscles, which 
favour the reduction, and throw out of operation those which oppose it, 
and thus restore the bone into its place : thus by a particular motion, the 
luxation of the thigh, at the hip, has been reduced in a moment, when 
without this happy effort of skill, it would have required immense power 
applied to the limb, with great suffering to the patient. Pathology and 
chemistry then separating the groups of facts thrown together by nature, 
before the mind in the one case, and anatomy in the other, furnishes the 
knowledge necessary for the cure. This system of analysis, which looks 
with an eye of scrutiny into the various masses and groups of natural 
phenomena presented in the human system, separating those which are 
united in the exact relation of cause and effect, and which the mind is so 
prone to view combined with others, in a confused and jumbled aggre- 
gate, is of the greatest importance, and it is by this process of separation, 
that science operates in conferring its benefits upon mankind. 

Let us then examine how this is effected. In proportion to the mass 
of correct ideas, acquired by the mind, are the capabilities of its useful- 
ness increased. For this purpose it is supplied with certain instruments 
— the senses. 

The mind may be considered as the granary, into which the senses, 
as the labourers, collect knowledge for future purposes. The wider the 
range of the power of the latter, the greater will be the harvest gathered 
by them. Thus the telescope by enlarging the sphere of vision, has dis- 
covered new phenomena in the heavens; and the tests of chemistry are 
assistant agents in rendering sensible qualities which would otherwise 
have passsed unobserved on the earth. The microscope may probably 
be employed to discover properties now unknown, and introduce us to 
a world of objects near to us, as vast and as curious for its minute- 
ness, as that of the great and distant objects, which the telescope has 
demonstrated. 

It is thus, then, by increasing the power of the senses, that science 
becomes more productive. When, however, we look around us, and 



INTRODUCTORY DISCOURSE. XV 

find that all nature, instead of being at rest, presents a scene of constant 
motion and change, connected and hung together in a series of indissoluble 
links, we are led to examine other relations of bodies ; relations which 
constitute the most essential parts of all knowledge — those of cause and 
effect. In medicine, their history is that of the origin and the cure of 
diseases; it therefore deserves minute and accurate investigation. Let us 
examine a few instances. Arrest the supply of oxygen to the lungs, and 
life ceases in the more perfect animals. Continued frost stops the fevers 
of summer. Emetics produce a discharge of the contents of the stomach. 
In all these instances, the effect is invariably and indissolubly connected 
with its cause. They have continued the same from the earliest obser- 
vation, and will do so to the end of time. Cause and effect are, therefore, 
the most important considerations of medical and all other sciences. 

What then is the nature of this indissoluble vinculum, which thus binds, 
for ages, in one continued series, the agents of physical nature together? 

When we contemplate the air, and the life of the animal, the emetic 
and the stomach, continued cold and certain fevers, we can discover no 
intermediate agent from which the effects produced, could, prior to 
experience, be inferred. The contact of the air with the lungs, of the 
emetic with the stomach, the appearance of frost, and their results, are 
all we know with regard to these phenomena. The first, the air, the 
emetic, and the frost, are called causes, as they produce certain phenomena, 
which are called effects; and as they follow them invariably, we expect 
the appearance of the one as the result of the operation of the other; a 
wise provision of nature, upon which all our operations in the regulation 
of our happiness is founded. Thus when a patient faints, or when life 
is suspended, the air is admitted more freely to facilitate recovery. 
When poison is taken into the stomach, an emetic is administered, or it 
is withdrawn by a syringe and a tube, because the qualities of the air in 
the resuscitation, and the emetic or the syringe and tube in discharging 
the contests of the stomach, are powerful ; they have been and always 
will be the same; we therefore operate with confidence, and success 
attends our efforts ; and this certainly depends upon the observation of 
the power of these respective agents to produce these certain and specific 
effects, and is the result of repeated experience. The essential and 
intimate nature of this power, however, cannot be understood. All we 
know of it is the observance of its general properties, and the circum- 
stances which modify them : thus, invariable antecedence is an essential 
attribute of a cause, as invariable consequence is of an effect, unless some 
adequate agent intervene to prevent it.* On the application of the finger 

* Med. Record, p. 120, No. 33. 



XVI INTRODUCTORY DISCOURSE. 

to the blaze of a candle, pain is produced; the eflect is uniform, and 
we avoid it ever after; and because the pain invariably follows the appli- 
cation of the blaze, which must as invariably precede, they possess one 
requisite of the relation of cause and effect. But in order to complete 
the relation of cause and effect, something more is necessary than mere 
antecedence : thus day precedes night, and night precedes day, and yet 
they are not the cause of each other, but both flow from the effect of the 
same agent, the sun ; day appearing as he rises, and night succeeding as 
he disappears. 

This something is the simple and constant observation of the effect, as 
the result of the cause; and it is the province of philosophy accurately to 
determine all those circumstances, which contribute to produce the effect, 
to separate those which oppose it, and to ascertain their power ; so that 
the resources of nature may be constantly within our reach, by an 
accurate knowledge of their causes. Thus it is, that by commanding 
the causes of things, we control also their effects. The conviction of 
the power of a cause must be clear and decided ; and it is proportioned 
always to the frequency of the instances in which it has been observed to 
produce the effect, provided there exist no collateral circumstances, to 
which it can also be attributed : thus, the effect of the sun in producing 
day has been so constantly and frequently witnessed, that it is impossible 
not to attribute it to that cause. When, however, a cause is observed 
less frequently, there will be some doubt with regard to it ; and this 
will be in proportion to the rareness of the observations made. Thus the 
fevers of summer have been attributed to bad food, bad water, and to 
mineral effluvia ; and as the system is often exposed to these agents, it 
is difficult to determine from observation, what is the exact power 
of each, or whether they have any agenc}', since they frequently operate 
on it at the same time and in union, with other causes, from which they 
had not been completely separated. Repeated observation, however, 
has cleared up the difficulty. Bad food, bad water, and mineral effluvia 
are found not to be the causes of bilious fevers, but exhalations from 
putrefactive materials of a vegetable or an animal nature. 

DIFFICULTY OF ASCERTAINING THE CAUSES OP MEDICAL PHENOMENA. 

The invariable antecedence of the cause, and consequence of the effect, 
ascertained from many clear and decided observations, are then the 
principal circumstances to be regarded in determining their nature. 
These apply to the dead as well as to the living worlds : but as the 
complexity of the phenomena of the human system is greater than that of 
surrounding^ nature; since it consists of masses of organs, each operating 



INTRODUCTORY DISCOURSE. XVll 

on the other, together, and on each other, for a specific purpose, the 
health and preservation of the wliole, it is evident that in proportion to 
the number of these organs must be the variety produced in the pheno- 
mena presented by the causes whiclu derange tlie system, and the danger 
of confusion in considering them. 

In the sensible phenomena, which are considered by natural philosopliy 
and chemistry, the case is widely dilFerent ; if one body is propelled 
against another, immediate motion, if the power is sufficient, is the 
result ; if one planet approaches another, they mutually move towards 
each other, and the effect is immediate, proportioned to their distance ; 
if two chemical bodies which have an attraction for each other are put 
into the same menstruum, tiiey act at once upon each other, and the 
phenomenon there ends. 

In every respect, both with regard to the shortness of the time inter- 
vening between the cause and effect, as also with regard to the simplicity 
of the phenomena, which follow the action of causes, there is less obscurity 
in the inanimate, than in the living world. In heahh and disease, there 
is in the living body a regular series of changes, which follow each other 
in stages, each of which may present a vast variety of phenomena, 
whose varying features have not yet been recorded : thus, as in the 
healthy system, the periods of youth, maturity, and decline, succeed 
each other, each characterized by its appropriate susceptibilities ; so in 
disease there is the same succession of stages : thus, in common inflamma- 
tion, heat, pain, and redness, form the first j pus characterizes the second, 
ulceration the third, and the process of healing, the last stage; in the 
erysipelatous species, heat, pain, and redness, the secretion of water, and 
lastly, branny scales. In fevers generally, the cold, the hot, and the 
sweating stages, form the succession. In each of these, however, there 
is some variety ; common inflammation may be arrested, and terminate 
in resolution, or instead of forming pus, it may end in scirrhus or in 
gangrene. Erysipelas, instead of being followed by blisters and scales, 
may also terminate in mortification. The causes of these deviations, 
however, can sometimes be appreciated ; thus, a plethoric and irritable 
state of the system, may produce mortification, in an inflamed part, or 
the quantity of the poison absorbed may produce a fever in which a 
chill does not appear, the hot stage commencing the attack. The regular 
order, however, of almost every disease, is characterized by ^com- 
mencement, maturity and decline, and this general feature appears to 
pervade all the operations of the system. 

The causes operating on the human body also vary in the precision 
and degree of their results ; at one time and in particular habits, pro- 
ducing slight, at others giv/di ancP decided eflVcts : whereas in the 
3 



XVm INTRODUCTORY DISCOURSE. 

phenomena of cliennistry and natural pliilosophy, causes are exactly 
measured by their effects : thus, if a pound weight be placed at one end 
of a lever of a certain length, it will raise a certain weight at the other 
end, and its power is determined by known laws;* and if a certain body 
is to be saturated with an acid, the necessary quantity can be ascertained, 
and all difficulty is removed in any future manipulations, provided the 
purity of the ingredients be known. In the operations of the human 
S3'stem, however, this is not the case ; thus, the quantity of the poison 
necessary to produce a bilious fever, is not known, though this disease, 
in certain climates, is very destructive; the degree of fever produced by 
it, or any mode of measuring that degree, is also unknown : the precise 
effect of certain states of the system, as plethora, which may increase the 
fever, are so likewise ; that of others, which exist exterior to the body, is 
also unknown ; as the influence of a high temperature in exhausting the 
system, &c. and producing a low or typhous disposition. To give another 
instance; the variolous matter inserted into the arm produces a pustule, a 
fever, pustules over the skin, and scabs, ending either in health or death. 
Some of the circumstances, which modify the fever are known; thus, a 
low diet previous to the inoculation, renders it mild ; but the exact strength 
of the disease is not to be ascertained by any precise admeasurement, nor 
the precise effect of diet in abating it ; its general course, and some of the 
circumstances that influence it, are ascertained, but the degree of this 
influence varies in difierent subjects, in a manner which our science gives 
no precise rule to determine or foretell ; this diflScult}' arises partly from 
the little attention which has been paid to the discovery of tests, for the 
various and peculiar states of the system ; and, secondly, to the inherent 
difficulty of the subject. It is a property of the living body to take on a 
violent reaction, on a slight cause at some times, at others to retain the 
regular tenor of health, under every variety of exposure; and this depends 
upon some secret cause within, known under the vague and uncertain 
epithet of predisposition or susceptibility to disease, which we have no 
test to measure or appreciate, except by the morbid resiilt. Thus, a man 
exposed to the miasmata, which produce the fevers of hot climates, will 
continue in perfect health, though his system is loaded with the poison, 
till he is exposed to a sudden cause affecting either his body or his mind, 
as a slower of rain ; the emotion produced by a frightful story, &c. From 
the*^^7mest state of health, his disease, a violent fever, suddenly appears, 
and the tendency to death is rapid, unless counteracted by some powerful 
agent, as affusion of cold water, which sometimes suppresses the disease 
at once; or by the use of blood-letting, or tartar emetic, which pal- 

* Parry's Posthumous Works. 



INTRODUCTORY DISCOURSE. XIX 

liates and luitigates the fever, till it terniiiiHte in recovery or death. The 
cause here appears to be quite disproportionate to the reaction, a few 
drops of rain developing suddenly a most acute and destructive fever; it 
is also irregular, for this same cause may produce it in a slight degree in 
one subject, whilst in another, no diseased action is the result, though 
both have been equally exposed to the causes, which produce the fever. 
This difference is said to be owing to a variety in the predisposition to the 
disease, for which we have no ceitain measure or means to appreciate, 
except by the result. 

In natural philosophy, astronomy, and chemistry, the case is different; 
there every thing may be weighed, numbered, and measured, and all 
the steps of cause and effect appreciated with the utmost precision. 
Till the same accuracy is obtained in medicine, an air of uncertainty 
must be thrown over the whole science. 

The same difficulty occurs with regard to the proper appreciation of 
the effects of medicines upon the system ; for the production and recovery 
from disease are regulated by the same principles. The system is a 
physical being, in which diseases are produced and removed by natural 
causes. Thus, if a medicine be given for the cure of a disease, from 
which the patient recovers immediately after the prescription, from the 
coincidence of the cause with the effect, the cure is attributed to the 
medicine. 

But as the powers of restoration of the system, may produce this effect 
as well as the remedy, it requires repeated observation to determine 
exactly, to which of these causes the operation of the remedy is owing ; 
and this is one of the essential requisites in appreciating the true power 
of every cause. The mere succession of the cure after the remedy is not 
sufficient: to give an instance; the triangular bone, a part of the human 
skull, was once given with confidence for the cure of epilepsy, and great 
efficacy was attributed to it, for a long series of years : at length, how- 
ever, the phosphate of lime, of which this bone is principally composed, 
was determined to be entirely inert, and the virtue of the remedy was 
attributed to the horror, excited by the associations created by taking a 
medicine prepared from the dead body, and not to its physical qualities. 
It is upon this coincidence of recovery with the exhibition of medicines, 
that the impositions of empirical practitioners depend : thus the virtues 
of nostrums for the hydrophobia, obtain circulation and confidence 
from the circumstance that it does not always follow the bite of a rabid 
animal. 

These cases, therefore, in which medicine is given before the disease 
appears, are often believed to be cured, when it would not have taken 
place. 



XX INTRODUCTORY DISCOURSE. 



MODE OF INVESTIGATING MEDICAL PHENOMENA. 

The properties of the system, and the nature of the remedy are neces- 
sary to be known from repeated and frequent trials before any accurate 
decision can be drawn; and as the body exhibits a series of functions, all 
going on at the same time, acting simultaneously and in subordination to 
each other, liable to be deranged by many causes both without and within 
its limits, the study of the nature of cause and effect with regard to it, 
has always been difficult, and requires the most accurate and persevering 
scrutiny and zeal in its prosecutors. 

As the restorative powers of the system are generally present, in per- 
sons taken suddenly sick from a state of health; and as the power of the 
remedy also ads at the same time, how can the efficacy of these two 
agents be determined ? In three ways, first, by determining the natural 
course of the disease, and thus appreciating in every stage the effects of 
the unassisted efforts of the restorative powers of the system : If they are 
insufficient, the effect of any remedy may be then proven. Thus it is ascer- 
tained that the venereal disease runs a certain course; first sores appear 
upon the genitals, then swellings in the groin, followed after a certain time 
by eruptions on the skin, sores in the throat, pains in the bones, &c. 
These symptoms succeed each other with considerable regularity; and 
end in consumption, caries of the bones, and death, if not arrested by 
some remedy : Mercury succeeds generally in putting a stop to it; and 
other remedies, as guiacurn, sarsaparilla, &c. assist ; but without it the 
natural progress of the malady is slow and steady towards the destruction 
of the constitution. By its exhibition, the symptoms are arrested and 
the patient recovers. Other diseases, as hydrophobia, run their course; 
they are fatal ; no remedy can arrest them. In both these cases, the 
natural progress of the disease exhibits a plain and uninterrupted course; 
in the one, the effect of medicine is plainly seen ; in the other its inefficacy. 
Some diseases, on the contrary, invariably terminate, after running a par- 
ticular course, in health ; as the vaccine disease, the chicken pox, &c. 

Secondly. By the immediate salutary eflect of the remedy restoring at 
once the system, in increasing the restorative power, and also removing 
the morbid cause; thus suddenly restoring health to the system. 

Thirdly. Where the restorative powers are in some instances suffi- 
cient for recovery, and in other cases they arc not, the experience of the 
efficacy of a remedy in a vast number of instances determines its value- 
then the restorative powers become a vanishing quantity, anil the excel- 
lence of the remedy is proved by the recovery of the system in many 
instances. 



INTRODUCTORY DISCOURSE- XXI 

Thus, a celebrated general, during a dysentery, finding the number ot 
his physicians too small, issued by their advice, a general order, that a 
certain quantity of Glauber salts should be administered to each soldier, 
at regular intervals : the army was accordingly soon freed from disease. 
Here the frequent deaths, and the sudden relief afibrded by the medicine to 
thousands, removed all doubt with regard to its efiicacy. During one of 
the campaigns of Austria in Hungary, the retinue of a certain count was 
entirely free from an intermittent which was general in the army, because 
bark was regularly administered to his followers : Here the number of the 
trials, and the continuance of the disease among thousands, who did not 
take the medicine, proved its efficacy. In the same campaign, the 
scurvy prevailed ; mercury was exhibited, and death was the uniform 
consequence; as the disease raged extensively, it settled the noxious 
influence of the remedy beyond controversy. 



REMARKS ON TWO OF SIR ISAAC NEWTON's RULES OP PHILOSOPHY. 

The rules laid down by Sir Isaac Newton, for the cultivation of natural 
philosophy, do not apply to the science of medicine, though often quoted 
with this view, viz. that similar effects proceed from the same or similar 
causes; and that we ought to admit of no other causes of natural effects, 
but such as are true, and sufficient to account for the phenomena. 

With regard to the first rule, that similar effects proceed from the same 
or similar causes, it is only sufficient to examine the causes of any one dis- 
ease, to show that it will not apply to medicine. Thus, the asthma arises 
from impure and smoky air, from a cold and foggy atmosphere, from 
the vapours of lead or arsenic, from frequent catarrhal attacks, from 
water in the chest, aneurisms, and other organic diseases. If, therefore, 
in every case of asthma, we inferred that its causes were the same, we 
should be much mistaken. The same thing may be said of all other 
diseases. 

With regard to the second rule, that we ought to admit of no other 
causes, than such as are true and sufficient to explain the phenomena; 
the first part of the rule is gratuitous ; a cause must be true, otherwise it 
is no cause at all. With regard to the second, the sufficiency of a cause 
to explain the phenomena, it wants precision, leaves too much to the 
mind, and opens an avenue to hypothesis. All the vagaries of medical 
theory, like the absurdities once advanced to explain the nature of 
gravitation, from the time of Hippocrates down to Broussais, have been 
believed to be sufficient to explain the phenomena, yet they have all 
proved unsatisfactory. Therefore, as the sufficiency of a cause to explain 



XXU INTRODUCTORY DISCOURSE. 

the phenomena depends upon the fancy of the interpreter, it is idle to 
take it as a test of its truth. 

To give an idea of the difficulty of investigating the causes of medical 
phenomena, the following remarks will be sufficient. 

The same causes, apparently under the same circumstances, will have 
different effects; thus, a current of cold air blowing on the upper parts 
of the body, produces in the same system, croup, or palsy of the muscles 
of the face : the same cause, apparently under different circumstances, 
will produce the same effect; thus, miasmata develope in every variety 
of constitution, the intermittent fever; which, when epidemic, assumes 
the character of almost all diseases. Different causes, to all appearance 
under different circumstances, produce the same effect; apoplexy is the 
result of the heat of the sun, of high living, &c. proving that the subject 
requires the most patient and unwearied attention and research : for the 
qualities of the air, of food, exposure, predisposition, Szc, all operate to 
give a distracted character to the face of medical opinion. 

It therefore becomes necessary to view the phenomena of disease 
with a single, cautious, scrutinizing and unprejudiced eye ; to trace, as 
far as can be done, every cause to its source, and to relieve the subject 
from embarrassing theories and hypotheses. From the limited nature 
of our powers, the phenomena are all we know; and it is the connection 
of two facts, in indissoluble and invariable succession, which constitutes 
the essence of causation, and it is the proper contemplation of this con- 
nection, which forms the real and solid acquisitions of science ; for the 
whole operations of nature are nothing more than an uninterrupted series 
of phenomena in this relation. In tracing the union of a cause with its 
effect, the mind, from the constant observance of succession, invests the 
cause with a quality, called power, the result of an instinct, which nature 
has implanted in us, and it is to the proper estimate of this agent, to the 
assignment to every body, its proper degree of power, and to the faithful 
record for the good of others, of the effects it may produce, that men 
derive character in the pursuit of science, for accuracy of thought or the 
contrary ; and it is also to the proper appreciation of the relative strength 
of the phenomena of nature, and the developement of our resources, 
according to that appreciation, that history stamps with the epithets of 
folly or of wisdom, of weakness or of strength, the various nations and 
ages of the world. 

Though the history of the operation of medical causes is obscure, from 
their variety and their conflicting nature, yet by a proper examination 
of them, great triumphs have been achieved over the most dreadful 
maladies ; and it is by observation, accurately appreciating the circum- 
stances, on which the efficiency of reme^es is decided, that the benefits 



INTRODUCTORY DISCOURSE. XXIII 

of our science are most conspicuous. Tiius, for instance, with regard 
to the treatment by venesection of inflammatory diseases, the most com- 
mon of all morbid affections: However hidden may be the seat of the 
inflammation — in the eye, the head, the lungs, if its symptoms be 
present, this plan of treatment effectually removes it, and prevents, when 
judiciously administered, the formation of abscesses, which almost always 
end in the destruction of the organ, and if the organ be necessary to life, 
in the death of the individual. 

The removal of the inflammation is as indissolubly connected with 
venesection as its cause, as the extinction of the spark when it falls upon 
snow, or with an explosion when it falls upon gunpowder are with these 
substances respectively, and its operation is with equal difficulty explain- 
ed : for the mind, in contemplating the abstraction of blood from the 
vessels, sees nothing more than the simple phenomenon and its effects, 
the debility and the removal of the disease, its consequent. Why the 
abstraction of the blood, should produce a diminished action of the heart, 
is equally inexplicable with the power of snow to extinguish the spark, 
or of gunpowder to produce an explosion, on the contact of that body. 
Reasoning from analogy, we should expect that the diminution of the 
quantity of blood in the vascular system, would lessen the mass to be 
propelled, and enable the heart to act with more vigour ; but the contrary 
is the case ; debility takes place long before a sufficient quantity is 
abstracted to lessen the mass of the blood, so as to aid its propulsion by 
diminishing its volume and weight. The phenomenon is purely vital ; 
we see that it is followed by its effect, the removal of the disease, and 
this is all we know upon the subject. This naked manner of contem- 
plating the operation of the causes, which -affect the human body, 
produces great certainty, as it is continually the subject of observation, 
and experience will rectify its errors. 

A cause, then, is merely a phenomenon, which is invariably antece- 
dent and connected with another, as its consequent; and this connection 
is expressed by the word power, which is given to the antecedent 
phenomenon, from its invariable order of occurrence. 

We shall now proceed to examine, in what hypothesis and theory con- 
sist, and attempt to show how far they are to be depended upon as the 
means of advancing our art. 

ON HYPOTHESIS. 

An hypothesis consists in the imagination of a cause which is supposed 
to intervene between the real cause, and that perceived by the senses.*^ 

* See Brown's Lectures on the Human Mind. 



XXIV INTRODUCTORY DISCOURSE. 

When a person, after being exposed to marshy exhalation, is taken 
with an intermittent, he is first afiected with a chill, in which the skin is 
corrugated on its whole surface. The marshy exhalation, and the con- 
stricted state of the skin, are the two first links of the chain of causes, 
which characterize fever, as perceived by the senses. Cullen, obeying 
the overweening propensity of the imagination, which attempts to satisfy 
itself by the invention of more satisfactory modes of explanation, 
attributed this state of the skin to a spasm of its fibres. Here then the 
hypothesis consists in the spasm, which intervenes between the miasmata 
and the chilly state, and which, though entirely fictitious, is said to be 
the cause of the latter. This hypothesis satisfied the celebrated professor 
and his pupils, till its novelty wore away, and the excitability of Dr. 
Brown, a more agreeable supposition, alike recommended by its novelty 
and unsubstantiated by fact, drove it from the field ; the same may be 
said of almost every other medical hypothesis. 

In Paris, there has arisen a new fancy, which fixes this imaginary 
being, intervening between the primary cause and the disease, in the 
intestines and stomach. Instead of the spasm of Cullen seated in the 
skin, and the excitability of Brown dispersed over the whole S3^stem, 
Broussais imagines the disease to consist of an inflamed state of the 
intestinal canal. As few persons die in the first attack of fever, it is 
difficult to prove the existence of this inflamed state of the lining mem- 
brane of this passage ; and besides, appearances of inflammation occur 
without any other cause than the simple powers of the arteries, and 
therefore any proof drawn from this source must be equivocal. Yelloly 
found that persons who had died from hanging, exhibited the mucous 
membrane of the intestines in a high state of apparent inflammation. 
Dr. Seeds and Dr. Parrish, state that animals bled to death, exhibited 
the same appearances. As it has been found, too, in cases of death from 
other causes, it is certain that when discovered after fever, particularly 
a long time after the first cause has ceased to operate, it cannot be con- 
sidered in any other light, than as an hypothesis. Dr. W. Phillips proved 
that the lungs and the stomach, were covered with injected vessels, in 
animals who died from dividing the par vagum. Mr. Brodie has shown, 
that arsenic applied to wounds, kills animals, and the stomach is 
found apparently inflamed, though no poison has been applied to it. 
These facts then show, that an inflamed state of the capillaries occurs 
from other causes, and in other situations ; and that it can by no means 
be regarded as the result of the operation of miasmata, though it is found 
among the morbid ])henomenu, which are discovered after death. It 
might with moie piopriety be considered as a result, than as a cause of 
that class of diseases j though even this is problematical, since it is 



INTRODUCTORY DISCOURSE. XXV 

discovered in subjects who have died suddenly from a state of the most 
perfect heahh. It is therefore only a concomitant of tiiese affections, 
and must, when regarded as their cause, be considered as entirely 
hypothetical. 

In chemistry, the same thing has frequently occurred. Previous to 
the time of the celebrated Lavoisier, the phenomena of combustion were 
explained by a principle called phlogiston ; this process was believed to 
consist in the destruction of that principle, and till it was again renewed, 
the body remained incombustible; sulphur, for instance, during combus- 
tion lost its phlogiston, and became sulphuric acid : if this acid was again 
exposed to chemical operations, which restored the sulphur to its original 
form, it was then said to have regained its phlogiston, and be susceptible 
ofa new combustion; this is a true example of an hypothesis; it is entirely 
an imagination, invented to explain a phenomenon, by the addition of a 
cause which has no existence. Its advocates, on finding that the burn- 
ing body acquired weight during combustion — that the sulphuric acid 
was heavier than the sulphur consumed, were obliged to invent another 
hypothesis to render the principle of phlogiston tenable : they supposed 
that the phlogiston lost by the sulphur, during combustion, possessed a 
principle of levity, which by its loss during the combustion of the sulphur, 
rendered the body heavier, a supposition, which i^ explained very satis- 
factorily, by the increase of weight gained by the sulphuric acid : this 
hypothesis, like the former, had the same defect; it wanted the evidence 
of the senses, and as it kept the minds of the most illustrious chemists of 
the last century employed in its support or refutation, much labour was 
lost, which might have been better directed. The union of oxygen with 
the combustible body, presents a simple explanation of this phenomenon, 
which is supported by fact and demonstration to the senses, without the 
aid of any creation of the fancy. 

This species of imagination is not, however, without its use. The 
mind, anxious in the support of truth, it has been said, is stimulated to 
inquiry, by the desire of substantiating the modes of accounting for 
phenomena, it may have invented. It therefore has a tendency to direct 
investigation to certain objects. It is, however, nothing more tlian the 
direction of an inefficient instrument to a limited range of natural obser- 
vation; an instrument which from its inadequacy may be well compared 
to a telescope, whose glasses are obscured ; when used to observe the 
appearances of the heavens, accident may with such assistance, make 
known some facts ; experiment, with better appointed means, must 
eventually determine them. 

The present state of chemistry, when pursued according to its purest 
principles, proves this truth. This science has arisen upon analysis, and 
4 



XXVI INTRODUCTORY DISCOURSE. 

has owed its success to the maxim that all bodies must be considered as 
simple, till they are pro^ved to be otherwise. It is a system of pure 
observation and inquiry, resting upon actual demonstration to the senses, 
without the admission of any hypothesis whatever. 

In reading the book of nature, however successful our conjectures may 
be, it is as absurd to suppose a knowledge of her operations previous to 
examination, as it is to obtain a knowledge of the opinions of men, before 
we study them ; and when we reflect upon the immense labour consumed 
previous to the age of experimental inquiry by adopting hypotheses as real 
interpretations of nature, the evils of this mode of inquiry will be pro- 
perly appreciated : they constituted almost entirely the doctrines of the 
ancient philosophers on physical science, and in the present age, medi- 
cine abounds with these follies : to investigate nature is to observe facts, 
and to mark the indissoluble connections with each other, as cause and 
effect, and thus in the operations of life to give efficiency and power to 
every effort, whether in the arts of taste, of convenince, or necessity. 
The nature of an hypothesis, then, instead of simplifying, really multi- 
plies causes, and envelopes in mystery the facts, of which true science 
consists. 

ON THEORY. 

Theory is not widely different :* it consists in the observation of a 
number of facts, noting the points, in which, the causes, which produce 
them agree, and characterizing in general terms their features of resem- 
blance, and thus forming a principle, by the knowledge of which, their 
peculiar operation may in all circumstances be exactly known and 
determined. Thus, it is observed that, in animals, a daily supply of food 
is necessary for their health and strength; and this general fact is drawn 
from reiterated experience, and a wide circle of observation ; but it is 
true, only within certain limits. If the position be confined to quadrupeds 
only, it is certain that considerable quantities of food taken daily, are 
found to be necessary for the perfect health of the animal. If we look 
into other classes of animals, as the amphibia, we find that the rattle- 
snake can live for many months without solid food of any kind, and 
grows fat; this circumstance again modifies the theory. Put the animal 
into the torpid state by cold, food becomes unnecessary for an undefined 
length of time ; and the first position, that all animals require considerable 
quantites of fluid and solid food daily repeated, is again modified, and 
shewn not to be universal. 

* See Brown on the Philosophy of the Human Mind. 



INTRODUCTORY DISCOURSE. XXVll 

The act of generation is essential previous to the re-production of 
every individual ; this is a general principle, which applies to quadrupeds, 
to birds, to the amphibia, and lo fishes. Tt is not, however, universal ; 
in some insects, two generations are re-produced without this operation, 
provided it be performed on the one preceding. In vegetables, the union 
of the sexes is not indispensable; the male and female exist on separate 
plants in the lombardy poplar* and weeping willow ;t the female of the 
former, and the nv^le of the latter, have never been brought to this 
country, and yet they are extensively propagated ; this princi[)le, then, 
is not at all universal. 

In chemistry, Lavoisier, from observing that oxygen entered into the 
composition of many acids, supposed that it was essential to all, and it 
was, therefore, denominated the principle of acidification. It, however, 
forms acids, alkalies, and bodies possessed of the properties of neither — 
oxides and water. The theory, therefore, falls to the ground. Again, 
all bodies possess attraction, and the harmony of the solar system is 
explained on this general principle. By it, the exact position of each 
planet in its orbit, at any given period, past, present, or future, can be 
ascertained, and it is called the Newtonian theory. To conclude, how- 
ever, that because the great masses of matter which roll through the sky 
obey this principle, that all others do, would be erroneous. Thus, a body 
thrown towards another, rebounds on approaching it within a certain 
distance; if glass be rubbed, light bodies are attracted and repelled by 
it; the position, therefore, that all bodies attract each other, is by no 
means general. Its precise limits can only be ascertained by observa- 
tion, and it is upon this circumstance that the value of the theory of 
attraction rests. These remarks extend to all subjects of physical and 
medical inquiry. Emetics evacuate the contents of the stomach, and 
when given in small doses, also the intestines; and this is true of almost 
every article of the class, and constitutes one great and valuable property 
of these bodies in curing fever. To say that it is universal, however, 
is not at all true. The sulphate of copper is enielic and astringent; a 
fact which, in cases of diarrhoea, where an emetic is indicated, is of 
great use. Theory, then, is nothing more than the inference that a 
property is common to many individuals, and is only pernicious when it 
is extended to cases, in which no observation has been made, and which 
is not justified by the nature of things. 

In the cultivation of science this observation is the great means by 
which all its truths are to be acquired. The mind and the senses are 
the instruments, by which it is effected : turned upon nature, whose 

* Populus dilatata. f Salix Babylonica. 



XXVIII INTRODUCTORY DISCOURSE. 

phenomena united to each other in indissoluble union, present continued 
successions of cause and effect, they perform the office for which they are 
destined when they collect the facts as they are, and refer to their proper 
sources, the powers from which they flow : avoiding hypothetical or 
imaginary causes; or the error of extending too widely the operation 
of those which are real, or the other extreme of limiting their range 
within narrower limits, than observation will justify. The cultivation 
of science is then a matter of common sense; and the comparative 
success of different individuals, is decided by their strength and industry 
in pursuing it. 

ON INVENTION. 

To some superior minds, these powers have been so lavishly bestowed, 
as to dignify them with the distinguishing epithet of genius. 

It is to genius, or the faculty of invention, that the greatest discoveries 
have been owing, and it is from the misapplication of this power that 
most of the errors of the world have originated.* The man who by 
great penetration invents the best means of accomplishing an end, when 
without his interference it would be impossible; who discovers in ordi- 
nary circumstances the seeds of useful improvement, which otherwise 
would have been neglected ; who restores order out of confusion, whether 
in the moral or the physical world, when the best interests of his species 
are in jeopardy, is deservedly regarded as a superior being. This 
quality of mind principally depends for its success upon the cautious 
examination of the relation of cause and effect, and it is upon accurate 
discrimination amidst the irregularities of nature, and a reference of each 
phenomenon to its proper antecedent, that the man of genius achieves 
the wonders, which distinguish him. This, however, is a painful and 
laborious task. To examine with labour, to collate, to separate effects, 
and to connect them with their proper causes, is a task to which few are 
equal ; whether the arrangement and formation of principles, or the more 
simple office of observation of individual causes, is the object. Genius, 
in its highest degree, requires a happy combination of judgment, memory, 
and imagination. If the former be predominant, whilst memory and 
imagination are deficient, the character is correct, though inactive, and 
phlegmatic ; if memory, it is disposed to survey the labours of others, 
rather than invent and make improvements ; if imagination, all its 
effects become more or less unreal and useless; and it is to this latter 
defect, that men of this class are most prone. Instead of collecting facts 

* Sec Brown's Lectures on the Human Mind. 



INTRODUCTORY DISCOURSE. XXlX 

and arranging them, they have been too much disposed to fly from the 
field df labour, and to wander in the more delightful and seductive 
paths of fancy. 

ON S03IE OF THE SOURCES OF ERROR DISCOVERED IN THE HISTORY OF 

MEDICINE. 

The science of medicine has now been cultivated for more than two 
thousand years. The most devoted industry, and the greatest talents 
have been exercised upon it^ and though as in other branches of know- 
ledge, there have been great improvements, and there is much to be 
remembered, yet upon no subject has the wild spirit and eccentric dispo- 
sitions of the imagination been more widely displayed, than in the history 
of medicine. Like every other branch of science, it presents an exten- 
sive series of examples of the aberrations of the human mind, driving 
wildly over the surface of discovery : and as these aberrations are inci- 
dental to every individual in pursuit of truth, and as they affect the 
practical operations of life, it is important to point them out, in order 
that the prevailing errors of the day may be avoided, and its truths 
adopted. 

I. The pride and vanity attendant on public stations and great 
celebrity, have contributed to augment the errors of science. Men of 
extensive fame glory in pretending to see deeper into the recesses of na- 
ture, than nature herself ever intended : they invent hypotheses, they build 
theories, and distort facts to suit these aerial creations. The celebrity of 
many of the most prominent characters of the last century, will, ere long, 
be discovered only in the libraries of the curious, and recollected only by 
the learned. Whilst the phenomena they pretended to explain continue 
in the same unvaried order, in the same beautiful succession, the fancies, 
with which their inventive imaginations have surrounded them, will be 
found to have disappeared with the fame, which gave circulation, and the 
authority, which enforced them on the easy minds of their respective 
ages. 

II. The susceptible character of youth, in adopting the crude sugges- 
tions or ingenious follies of their teachers, leads also to error. It is 
necessary that authority should have weight; and it is the result of the 
limited range, within which attention is circumscribed by the multifarious 
occupations of life 5 the judicious and independent decide for themselves ; 
the feeble and the flexible, borne down by the current of authority, adopt 
alike the truths and errors of the age, and become the saviours or the 
destroyers of their fellow men, according as chance may have cast their 
lot upon life's wayward stream. The modest and the humble, decide 



XXX INTRODUCTORY DISCOURSE. 

with caution and deliberation, and their opinions are valuable; the 
arrogant and the self-sufficient are hasty, and they are dangerous. Truth 
is an object dear to every well regulated mind ; vanity, the desire of 
superiority, or indolence, may conceal or destroy it ; judgment, candor, 
industry, and zeal in enforcing, supporting and promulgating it, are 
qualities, which claim the respect, as they deserve the gratitude of 
mankind. 

III. A more fruitful source of the errors of the scientific world, is 
derived from that disposition, which induces explanations of the pheno- 
mena of nature, by principles drawn from subjects with which the mind 
is more familiar. This mode of philosophy has been of extensive evil in 
medicine. During the prevalence of the mechanical, chemical, and 
mathematical systems of philosophy, all the changes of the body were 
referred to them : the doctrines of Keil, Paracelsus, and Borelli, who 
attempted to explain the phenomena of life by the sciences with which 
they were most conversant, still remain conspicuous instances of this 
error. During the prevalence of chemistry in the age of Louis the XIV. 
vast labour was bestowed in analysing vegetable remedies, from the belief 
that the diseases of the human body were produced by an acid or an 
alkali, which was supposed to pervade the system, and that it was neces- 
sary to discover which of these principles every remedy possessed. This 
folly was relinquished, after finding that the most noxious and the most 
innocent substances were composed of the same ultimate materials; that 
the poison of the viper and gum arable owed their qualities to a various 
disposition of the same elementary substances. It is no later than the 
conclusion of the last century, that the most enlightened physicians ex- 
plained many of the phenomena of life, on the supposition of the presence 
of too large a quantity of oxygen in the system : the late revival of the 
use of the magnet in the cure of tic doloureux, rheumatism, &c. by some 
of the most able physicians of Europe may, with propriety, be referred 
to the same disposition of mind to be directed and biassed in its pursuits, 
by the fashions of science. Other branches of knowledge obey the same 
influence. 

Metaphysicians still speak of impressions, as if our thoughts were the 
result of impulses, or our ideas of images reflected from a glass. Indeed, 
so prevalent is this source of error, that it is almost impossible to divest 
ourselves of its influence. Electricity has been introduced to explain 
the phenomena of the system, and was once extensively employed in 
removing its diseases ; and galvanism, now a more conspicuous object of 
attention, fills the same oflice in the present philosophy of the nervous 
system. 

IV. The disposition to simplify the causes of nature, has had an 



INTRODUCTORY DISCOURSE. XXXI 

equally extensive effect. The excitability of Dr. Brown explained, with- 
out difficulty, all the phenomena of the body: the pain which was produced 
by a red hot iron, and the pleasurable sensation excited by the softest 
substance, the irregular and terrible symptoms of the hydrophobia, and 
the sensations of perfect health, were all expressions of the various states 
of the same power, which under the bold and hardy invention of this 
innovator in medicine, explained all the phenomena of our complicated 
system, from the greatest to the least. 

The four elements, earth, air, water, and fire, to which every thing 
was resolved by the chemists, illustrate the same defect. The pro- 
perties of medicines, in fact, of all bodies, were once believed to be 
reducible to four; to heat, to cold, to moisture, and to dryness; and 
from hence arose the temperaments, the bilious, the phlegmatic, the san- 
guine, and the melancholic, a division which, though it prevails to this 
day, is as groundless as the qualities, upon which it originated. This 
disposition to simplification, however, is only defective when in excess, 
and conducted by hypothesis, and not by observation and experiment. 
Tlie theory of gravitation, embracing in the wide compass of a single 
principle, all the phenomena of the ocean, the air, and the land, the 
planets and the comets of our system, exhibits a splendid result of this 
faculty. The variety, the beauty, the order of this vast sea of effects, 
the result of only one quality of matter, whilst it enlarges our ideas of the 
Creator of the universe, gives a happy illustration of the proper appli- 
cation of this menial propensity — the proper arrangement of facts under 
their proper causes, by the faculty of generalization. 

But if, extending this great principle beyond its proper limits, we 
venture to embrace in it the phenomena of the attractions of affinity and 
of aggregation, of electricity and magnetism, it is found to be inadequate, 
and we fall into error. There is great simplicity in the works of nature; 
they are united and moved upon one great plan, but placed as we are 
without the curtain, we can only discover by the observation of the phe- 
nomena, how far the operation of a principle extends, and to attempt to 
simplify farther, leads to erroneous conclusions. It is to this love of 
simplicity, that mankind owe the attempts of empirics to effect cures by 
medicines, which unite in the compass of a single substance the power 
of relieving all diseases. The mystery, in which they are enveloped 
stimulates curiosity, and the patient pays largely to the pretender for his 
health, whilst nature performs the cure. It is to the same mysterious 
pretension, that boastingly promises to relieve hydrophobia, cancer, 
and other diseases beyond the power of our art, that the success of this 
species of imposture is owing. 



XXXll INTRODUCTORY DISCOURSE. 

It is said that mystery of explanation, as it entices youth to study, 
has a highly beneficial efiect. That it has great power over the mind, 
is clearly proved from the fascination it throws around the modern tales 
of fiction ; from the great efiect it gives to the character of freemasonry, 
an institution which has been of extensive benefit, and under the direc- 
tion of bad principles has lione much mischief in the world. The same 
cause increased the celebrity, influence, and efiect of the elegant letters 
of Junius, which kept in a slate of alarm the jealousy of British liberty; 
and the story of the man in the iron mask, on the same principle, gave 
interest to an incident little more important to mankind than an idle 
Arabian tale. 

V. The errors produced by one extreme, induce mankind to embrace 
the contrary. In the early ages of every science, occult qualities claim 
great attention. Among savages, every phenomenon of nature is sup- 
posed to be produced by spirits, which have their residence in the bodies, 
which they move. As philosophy advances, these imaginary creations 
are rejected, and every thing is supposed to be the result of natural 
causes ; and thus from the extreme of superstition, they pass into 
atheism. 

VI. The efiect of superstition appeared extensively in the first appli- 
cation of chemistry to the materia medica. The influence of the planets, 
alchemy, animal magnetism, the discovery of panaceas, and of medi- 
cines capable of prolonging life, are enumerated among the follies of 
that era. 

VII. The doctrine of signatures, which ascribed virtues to remedies 
drawn either from the figure or the colour of the plants, from which they 
were taken, had an extensive sway, and it is only within the last seventy 
years, that it has been banished from the elementary books of the most 
respectable schools of Europe. 

viii. All the phenomena of the natural world were explained by Des 
Cartes by matter and motion, a doctrine, which followed that of occult 
qualities, which his predecessors supposed to be the active powers of the 
physical world. The influence of this system was extensive upon our 
science at one period. The action of medicines was explained upon the 
principle that the corpuscles of bodies operated upon each other by 
their figure, size, and density; so wide spread and lasting was this error, 
propagated principally by the influence of the great Boerliaave, that a 
celebrated writer as late as the conclusion of the last century, explained 
the operation of mercury by its specific gravity. 

IX. The accurate descriptions of disease, and the examination of 
remedies, by Boerhaave and CuUen, gave way, for a time, to the specious 



INTRODUCTORY DISCOURSE. XXXUl 

doctrine of stimulation of Brown, who believed in only ooe species of 
remedy and two forms of disease : the science lhi\s vibrated between a 
coniplication of remedies, in the time of Boerhaave too complex, and in 
that of Rrown too simple. 

Tills disposition to pursue extremes, applies particularly to the adop- 
tion of new remedies. When a medicine has been too much extolled, 
opinion weakened by habit, and by the current of fashion directed to 
other remedies, at length discards it altogether : Mercury, in the cure of 
syphilis, long balanced between excessive and blind partiality, and utter 
rejection ; at length, after sarsaparilla, nitric acid, opium, guaiacum, 
which at various periods had adopted its place, had been fairly tried and 
abandoned, it was again reiustated. At present, in England, it suffers 
a temporary defection in public opinion; and though no substitute has 
been proposed, there can be little doubt, that at least the constitutional 
symptoms of that terrible disease must be ultimately cured only by this 
remedy, for it is satisfactorily proved, in small doses, to afford the 
best relief in those chronic inflammations, and ulcers produced by its 
improper exhibition. 

X. The passions of physicians have proved of essential detriment to 
the advancement of their art. This point is so evident, that it hardly 
re(juires discussion. The disputes betwen the followers of the Grecian 
and the Arabian physicians, occupied a great part of the sixteenth cen- 
tury; those of the followers of Galen and Paracelsus were equally warm, 
and equalJy futile, leaving the science comparatively little cultivated, 
when the works which are the result of their labours are considered. 
The faculty of Paris, under the dominion of Galenical medicine, pub- 
lished a decree against the use of antimony, which was rescinded only 
as late as the year iGGG; a proof of the folly, as well as the pernicious 
effects, which attend the operation of disputes in medicine as well as 
those of religion, when inflamed by opposition. The prejudice in favour 
of particular remedies produced by fashion, eives a temporary excite- 
ment to the medical mind, which in most instances is excessive. The 
influence of the celebrated Stork of Vienna, introduced narcotics in the 
cure of scirrhus, a prejudice which occupies, in cancer of the womb, 
considerable, though undeserved attention to this day. The weight and 
respectability of men acquainted with medicine, incautiously given in 
favour of particular remedies, has had much influence in exciting the pre- 
judices of physicians. The celebrated Mr. Boyle made a considerable 
collection of remedies of supposed experienced virtues, which for a time 
claimed attention, with but little improvement to the science; the 
powder of the duke of Portland, used in gout, will long remain a fatal 
instance o( the credulity of our science, excited by a great name. The 
5 



XXXIV INTRODUCTORY DISCOURSE. 

eau medicinale d'Husson, more lately, may be placed under the same 
head. 

XI. The errors, which arise out of the use of improper language, are 
equally extensive. It is evident, in a science which professes to treat of 
phenomena so concealed, and with difficulty measured, as those of the 
human system, that its descriptions must be general, vague, and unsatis- 
factory, without a language rigorous, precise, and properly adapted to 
its varying modifications and changes : the different kinds of pain, the 
nameless combinations of symptoms exhibited in the same disease; the 
appearances of the tongue; the various states of the pulse and of the 
secretions, are all important to designate the precise state of the 
system, and have, in our present medical language, very imperfect 
expressions. 

The perfection then of every science consists in the exact assignment 
of efiects to their causes, and the expression of their operation, in intelli- 
gible language. The process is simple, and observation is the great 
means of its accomplishment. 

In order to appreciate exactly the difference between the medical 
character of the United States, and that of Europe, it is proper to take 
a review of our climate, manner of living, and diseases. 

ON THE CLIMATE, MANNER OF LIVING, AND DISEASES OF THE UNITED 

STATES. 

This country stretches from the 30th to the 47th degree of north lati- 
tude, and embraces a vast diversity of climate and of soil ; — exhibiting 
the animal and the vegetable kingdoms, in all their variety ; and as the 
human frame is, in its various portions, exposed to almost every spe- 
cies of temperature and treatment, there can hardly be named a single 
disease which does not exist in the United States.* As they are flanked 
on one side by an impenetrable forest, and have an ocean equally exten- 
sive on the other, the comparatively narrow tract which they embrace 
is subject to the dominion of the winds produced by these two great 
natural magazines. Our seasons are accordingly in perpetual variation ; 
though, at the same time, the cold predominates in the north, and the 
hot in the south ; — while those of the middle states are constantly 
vibrating from the one to the other. Nothing, in short, can exceed the 
variableness of our climate; for we can truly say with the Spectator, that 
we frequently ' lie down in July, and rise in December.' 



• This Essay was originally piiblishcul in the Analcctic Magazine, by the 
author of this (hscourse. 



INTRODUCTORY DISCOURSE. XXXV 

In Pennsylvania, there are seldom more than thirty or forty days 
of summer or of winter, in which the mercury rises above eighty, or 
sinks below thirty degrees of Fahrenheit's thermometer. The winter 
generally commences about Christmas, and continues till the beginning of 
March: April is raw and often showery; May still retains the moderate 
coolness of spring; June introduces summer; July and August are 
the hottest months ; but in the latter the mornings and evenings begin to 
be cool, and in September the days are pleasant and delightful. The season 
is then generally the most equable, and the country the most attractive. 
The trees are variegated with foliage of a great variety of colours ; and 
instead of the sombre and melancholy drapery of European forests, they 
have a gay and enchanting appearance.* 

In summer we have days which are uncomfortable without fire, and 
in winter some which are disagreeable with it. Garlic, a vegetable 
which is common in the eastern parts of the states, has appeared in Jan- 
uary; other plants have blossomed in December and in February; and 
yet in the very same months the thermometer has sunk as low as 
twenty-two degrees below 0. The autumn and spring exhibit all these 
varieties; more particularly the latter; which is still affected by the 
contests of the sun, growing every day more powerful, with the northern 
and western winds sweeping across the vast surface of the continent, 
between the United States and the Pacific ocean. Pennsylvania exhibits 
in the spring the moisture of the British isles; the heats of the tropical 
countries, in the summer ; the sky of Barbary in the autumn ; and the 
atmosphere of Russia in the winter. There is no month in which frost 
has not made its appearance, or in which fires have not been found 
necessary .t Taking the climate of Pennsylvania, then, as our point of 
observation, we see a vast continent, surrounded on the north and west 
by extensive forests, stretching their almost immeasurable bounds to an 
ocean many thousand miles distant, and experiencing in its extent the 
cold of the arctic circle, the moderation of the middle latidudes, and the 
heat of the torrid zone; on the south a burning country, moderated and 
broken by huge mountains, and on the east by an ocean equally exten- 
sive as the forest on the west, and equally fruitful in storms and variable 
seasons. The consequence which naturally attends our position between 
these two grea^ natural deserts, is, as was before observed, that unceas- 
ing changes are taking place in our climate. The north differs from the 
south in having a surface more vexed by winds, — though cold predom- 
inates; the middle vibrates alternately to both extremes; while the south 
is more under the genial influence of the sun. 

^ Rush's Works. i Ibid. 



:5XXV1 INTRODUCTORY DISCOURSE. 

As tlie western districts of the country are divided by great niountainsj 
they have in general a milder temperature than the eastern. The effects 
of the winds upon health are pretty accurately measured by the follow- 
ing arrangement: as the north and north-west are rendered severe in 
winter by passing over interminable snows, — but moderated and moist- 
ened in summer by accompanying rains, they in v^inter invigorate, and 
in summer refresh the inhabitants of the states and territories which lie 
east of the Mississippi. Proceeding to the south, the winds traversing 
the ocean in that direction, Mexico and the south-western states, lose 
some of their moisture, and have a still more debilitating effect; which 
increases as we proceed towards the east, till we come to that quarter 
where cold and moisture both combine to affect the wind in the highest 
degree. We find few men above forty who are not susceptible of its 
chilling and depressing effects. The cold and dry air of the north lati- 
tudes, the moist and relaxing breezes of the south and west, the chilly 
raw currents from the eastward form, in general, then, the character of 
the winds which disturb and perplex our climates. 

Our m.ode of living, with regard to dress and diet nearly resembles 
that of our English brethren. Coffee, bread, meat, and butter, consti- 
tute our breakfast; the domestic animals and vegetables which are eaten 
by the Europeans, furnish our dinner ; whilst the third and the last meal 
generally consists of tea and bread, with perhnps a little animal food. 
Our drinks are also nearly the same ; the native liquor distilled from rye, 
constituting the beverage of the labourer; brandy, gin, spirits and 
Madeira wine, that of the higher classes. We differ from our ancestors, 
however, in eating more animal food, and drinking more spirituous 
liquors; though, as to the latter article, perhaps, it may safely be said, that 
the consumption of these destructive and pernicious stimulants increases 
by degrees as we go from the north to the south. In the eastern states, 
the people are thrifty,' active, and industrious, — drinking little ardent 
liquor of any kind: but as we approach the middle states this vice 
augments, whilst industry necessarily decreases; and when we come to 
the southern districts we see intemperance prostrating her victims on 
every side, and bringing along with her the usual train of lazy habits 
and dissolute morals. If we have any vice which can be called national, 
it is inUmpcrance : The quantity of liquors consumed yearly is pro- 
digious. 

With regard to our diseases, pleurisies, rheumatisms, and inflamma- 
tions generally prevail during the winter in the northern states. Catarrh, 
too, is common, and often terminates in the comsumption; which may 
be called llic endemic of the country. In some districts and seasons, one 
fourth of the number of deaths are fiom this cause. The various forms 



INTRODUCTORY DISCOURSE. XXXTll 

of quinsy occur frequently ; nor are local inflammations of the internal 
parts of the body by any means uncommon. The eruptive diseases, — 
such as the scarlet fever, the measles, &c. occur generally at the interval 
of three, four, or more years : — but the small-pox, since the introduction 
of the vaccine, has certainly been suppressed as far as the irregularities 
of poverty, ignorance, and prejudice will permit. It is a lamentable 
truth, however, that this loathsome disease is still seen in our cities. 
The plague, exactly in the form which it wears in the old world, has 
seldom appeared in our country. The disease of Pemphigus, and mili- 
ary fever, are not often seen. Apthae and cholera, particularly among 
young children, appear in the summer, when the heats are great. The 
nettle rash is common among the adolescent, — but more rare in adults. 
Haemorrhages, both active and passive, are known in all climates of the 
country, and cannot perhaps be said to belong to one district more than 
to another, — excepting that from the lungs; which is not uncommon in 
the northern districts, and most generally precedes the consumption. In 
the southernmost regions it is almost unknown. Haemorrhoids are 
often an affection of the old ; and perhaps, indeed, it may be said that, 
with respect to this disease, as well as to others, not immediately con- 
nected with our variable climate, we resemble the inhabitants of Europe. 
With regard to the diseases peculiar to the sex the same remark may be 
made. 

Apoplexy and palsy are often the result of intemperate habits ; in the 
middle and southern states particularly. They are the diseases of which 
the aged die, in the concluding months of winter, as well as at the begin- 
ning of spring or of autumn. The active habits of our countrymen ren- 
der hypochondria more rare than in Great Britain. In the northern 
states the tetanus or lockjaw, is uncommon, in summer, and never occurs 
in winter. In the middle states, it is dangerous to receive a wound, 
particularly a lacerated one, during the warm season, without using stim- 
ulating remedies to prevent this dreadful disease. In the southern, it is 
not at all infrequent in suiyraer, and it sometimes occurs even in winter. 
In the former seasons it often proceeds from a cause, viz. exposure to the 
night air, which in the northern states is seldom or never known to pro- 
duce it. Of epilepsy, asthma, and St. Vitus's dance, there is nothing 
peculiar to be said with regard to our country. Pyrosis and indigestion, 
are often the result of intemperance : they are confined to no particular 
district, or tract ; and may be said to attack in the common forms and 
from the ordinary causes. Hydrophobia appears not unfrequently ; and 
is often symptomatic, — though it most commonly arises from the bite of 
rabid animals. Madness, indeed, may be supposed to arise in this coun- 
try from the same occasional causes, as in Europe. It appears in families. 



XXXVIU INTRODUCTORY DISCOURSE. 

and descends by hereditary succession; often disappearing in one branch, 
or generation, and making its appearance again in another. Sometimes 
high-toned pride, intemperance, excessive headachs or eccentricity, in a 
parent, becomes mania in the next generation ; while on the contrary, 
they leave a family in a reverse order. Religion, love, and losses in busi- 
ness, may perhaps be the most frequent causes of this disease, though 
from its connection with hereditary perdisposition, it is often difficult to 
trace them with accuracy. 

Dropsy is believed to be less common, than formerly, and is now a 
very manageable disease, where the constitution is not absolutely broken. 
It generally occurs among the poor, the irregular, and the intemperate. 
Rickets rarely appears ; though it sometimes affects tlie negroes, and 
particularly negro children. Scrofula occurs more frequently ; and is 
generally manifested in diseased mesenteric glandular swellings, and 
ulcers of the soft parts, with carious bone. With regard to the disease 
resulting from impure connexion, it may be supposed, that, in a country, 
where population is extended on a scale unknown in any other quarter 
of the globe, — where all the delights of life highly stimulate the system, 
the diseases of a function so intimately connected with the general health 
would naturally be common. Accordingly, it may be said, that among the 
labouring classes, particularly in the cities, there are few individuals, who 
have not had their constitutions seriously affected by frequent contami- 
nations, by i-njudicious exhibitions of mercury, or by suffering the malady 
to go imperfectly cured or totally neglected. To give the reader a general 
view of the state of disease in our country we would say, that malignant 
bilious fevers of remittent or an intermittent type, prevail most in the 
summer and beginning of autumn ; catarrhs, pleurisies, inflammations, 
rheumatisms, typhous fevers, in the approach and progress of winter, as 
well as in the commencement of spring, — and that the other diseases, 
which have been enumerated, are regulated in their appearance by irre- 
gularity of living, by the decay of nature, and by the other numerous and 
varying accidents of life and of climate. Accordingly in the north, where 
winter has the sway, the remittent fevers of the summer are more mild, 
and the inflammations more severe. But in the south, the contrary 
takes place, — the fevers being malignant and deadly; whilst inflamma- 
tions, pleurisies, catarrhs, and consumptions, seldom occur or are entirely 
unknown. In the middle states, on the other hand, where the climate is 
alternately tropical and arctic, we have, according as the one or the 
other season prevails, the malignant fevers of the south, — or the con- 
sumptions, and the inflammations of the north. From this view of the 
climate and diseases of our country, it need not be said, that various dis- 
tricts have various dej^rees of health ; that the sea, lakes, marshes, high- 



INTRODUCTORY DISCOURSE. XXXIX 

lands, and mountainous regions diversify the temperature of the air, as 
well as the character of disease ; that epidemics appear in districts, for 
many years blessed with health ; and that while there are endemics, 
which never leave particular regions, — there are others which, at all 
seasons and in all years are comparatively free from diseases of any 
kind. 



PART I. 
ACUTE DISEASES. 



CLASS I. FEVERS, 



CHAP. I. 

GENERAL DOCTRINE OF FEVER. 



Importance of the Subject — Fever how characterized — Of Ri- 
gors and Heat of Skin — Frequency of Pulse — Loss of Muscu- 
lar Poiver — Disturbance in the Functions of the Stomach — 
Other Functions disturbed in Fever — Leading Divisions of 
Febrile Diseases— ^Causes of Fever, predisposing and occa- 
sional — Nature of Fever — Periodic movements observable in 
Fever — Principles of the Treatment of Fever. 

IMPORTANCE OF THE SUBJECT. 

Fever is the most important, because the most universal and the 
most fatal of all the morbid affections of which the human body is 
susceptible. Its presence characterizes a great number of diseases; 
and in others which are not for the most part attended by it, the 
Physician must always be prepared to expect its occurrence. It is 
that, by the presence or absence of which all his views of treat- 
ment are to be regulated; whose rise, progress, and termination, he 
always watches with the closest attention, and by the degree of 
which, he is enabled, in a great measure, to estimate the danger in 
each particular case. Some idea may be formed of the great mor- 
tality of fevers from the statement of Sydenham, who calculated 
that two-thirds of mankind die of acute diseases properly so called, 
and two-thirds of the remainder, of that lingering febrile disease, 
consumption. Fever has proved a fertile theme, on which the 
ingenuity of physicians, in all ages, has been exerted; and a glance 
at the attention which it has recfeived from every medical author, 
both ancient and modern, would be sufficient to impress upon any 
one the importance of the doctrines it embraces. How difficult, 
lastly, is the study of fever may be infei^red from this, that though 
so much has been written concerning it, there is no one subject in 
the whole circle of medical science which still involves so many 



44 GENERAL DOCTRINE OF FEVEK. 

disputed points. In every view the doctrines of fever must be con- 
sidered of paramount importance, and they constitute, therefore, 
with great propriety, the foundation of all pathological reasoning. 

FEVER HOW CHARACTERIZED. 

When a person is suddenly attacked by shiverings or rigors, fol- 
lowed by a hot skin, a quick pulse, and a feeling of languor and las- 
situde, he is said to have an attack of fever. With such symptoms 
are usually present also a loss of appetite, and thirst; restlessness, 
and diminished secretion. These constitute the six leading symp- 
toms of fever, the characteristic features by which its presence may 
always be detected. Every function of the body indeed is more 
or less disturbed, but we select for the definition of fever those 
w^hich are of the most importance in the animal economy. The 
marks of disturbance in them afford the characters of fever just 
enumerated, and of which we now propose to treat in detail. 



RIGORS AND HEAT OF SKIN. 

1. Chilliness, succeeded by increased heat of skin, is the first and 
leading feature of fever. The chilliness or rigor is sometimes so 
slight as almost to escape the notice of the patient. At other times 
it is exceedingly violent, so that he complains bitterly of cold. His 
teeth chatter. His limbs tremble. The skin is pale, rough, and 
contracted. The features shrink. A sensation is felt as of cold 
water trickling down the back. 

In some instances it has been so violent that the patient has gone into convul- 
sions ; in others some of the teeth have been knocked out : also, syncope, death- 
like rig-idity of the limbs have occurred ; and after the fit the power of motion has 
been almost lost : sometimes the cold is partial, affecting- one part of the body ; 
sometimes it is external only.* 

Though the author mentions, that chilliness is the first symptom of fever, it is 
so only in its simpler forms, for there are many cases in which it docs not occur at 
all, and when it does, it is often preceded by languor, weariness, yawning- and 
stretchingjf with great weakness and restlessness, and a slow and small pulse. 

The prominent characteristic of this stage is a weakness of the heart and arte- 
. ries, as is shewn in the weakness, frequency, and irregularity of the pulse ; the 
consequent shrinking of the extremities, as of the fingers, and also of tumors ; the 
suspension of the discharge from sores ; the coldness and want of sensibility oftlie 
feet or hands ; horripilation, or a feeling as if insects were creeping over the hairs 
on the surface ; a wrinkled and shrivelled state of the skin also accompanies it. 
Pain in the head, back, and limbs, is also one of the first symptoms of fever. The 
respiration is more hurried and anxious, with a sense of weight, and often of tightness, 
about the chest ; cough, sighing, and dejection of spirits. t The senses are more 
or less impaired during this sUtge ; the mind also is weakened, it is impossible to 
keep up the attention to any one subject*; agreeable thoug-hts become disagree- 
able, and delirium often comes on as the chill advances ; the appetite, particularly 
for animal food, tobacco, and all stimulants, is lost ; bile is secreted in great quanti- 

• Pliilip, p. 54, on Feb. Dis. Lond. 1813. f Ibid, p. S5. 

\ Ibid, p. 56. 



GENERAL DOCTRINE OF FEVER. 45 

lies in the lust moments of the chill, and the patient becomes sick, nauseated, and 
vomits it pure ; sometimes a ropy transparent fluid is discharj^ed, the bile being- 
then carried oflT by the intestines. The urine during- the cold stage is clear and 
colourless, without cloud or sediment.* C. 

The duration of tlic cold stage varies from an hour to two or 
even three days. Though often very slight, it is perhaps never 
entirely wanting; and is at all times to be carefidly inciuired for 
and noted by the physician, as marking the precise period of the 
accession of fever. This it is useful to know in all fe])rile diseases; 
but in some, as small-pox and measles, it forms the basis of our 
prognosis. The coldness of which the patient complains, is some- 
times, though not always, perceptible to the touch of another, but 
never to the extent that might have been anticipated from the 
suiTerings and expressions of the patient. 

When the remote cause inflicts a deep wound upon the nervous system, the 
patient sometimes dies in the chill — sometimes in the first, though more frequent- 
ly in the second or third paroxysm. In such cases the increased heat and action in 
the extreme vessels ai-e never developed : hence it is generally to be observed, 
that the shortest chills are succeeded by the most inflammatory fevers, and vice 
versa. If the disease be well managed, it may be conducted to a safe issue, with 
a facility in the exact ratio of the degree of fever. The duration of the chill for 
'* two or three days," is not a frequent occurrence, where medical aid is oppor- 
tunely and judiciously administered. If the inflammatory symptoms run high, it is 
eflectually destroyed by blood-letting and the auxiliary antiphlogistic^means : if the 
fever assume a low type, emetics, cathartics or tonics, agreeably to indications,, 
remove it, unless some organ highly essential to life shall have been too deeply 
involved. P. 

By degrees the chilliness subsides, and begins to alternate with 
warm flushings. A heat of skin greater than natural succeeds, and 
with it returns the colour of the skin. The cheeks become even 
flushed, and the eyes suffused. The features recover their usual 
size, or appear more turgid than in health. The hot stage of fever 
is then said to be formed, which may go off* in a few hours, as in 
the case of an ague, or may continue for days or weeks, as in 
common continued fever. 

The heat often rises to 105° Fahrenheit ; the breathing becomes deeper, less 
anxious, slower, and more free, the sense of tightness gradually dechning ; the 
sensibility is increased ; the pains of the head, back, and limbs continue ; light, 
noises, and busthng motion in the room, are painful ; delirium, or confusion of 
thought, takes the place of the stupor of the chill, as the pulse increases in 
strength : the urine becomes high coloured and without sediment: Whilst the 
pulse runs high, hoemorrhages from the nose, womb, ears, lungs, and from piles, if 
the patient be subject to them, are not uncommon ; and under these circumstances 
in inflammatory fevers, are generally favourable. Tumors, and the general fulness of 
the body increase as the hot fit goes on, till the sweating stage appears: After 
the hot stage has continued for some time, the sweating commences generally on 
the upper parts of the body, the fes])iration becoming easy, free, and natural, the 
pulse abating, and the urine depositing a lateritious, or brickdust coloured, and 
often a whitish sendiment ; the patient feehng weak or exhausted, after the sweat 
has continued some time: 

These symptoms occur in the common intermittent, and characterize more or less 
all fevers, with some irregularity: thus, as was before observed, the cold stage is 



CuUen. 



46 GENERAL DOCTRINE OF FEVER. 

often wanting; and sometimes the hot stage, a cold and clammy sweat commencing 
the attack; or the hot and sweating stages go on simultaneously, the chUl being 
omitted; indeed cases are recorded, in which the cold, the hot and sweating stages 
were completely reversed: The symptoms of fever often personate those of all 
other diseases, as pleurisy, rheumatism, phrenzy, epilepsy, apoplexy, hydrophobia, 
hysteria, gravel, in fact every morbid affection whether acute or chronic to which 
the system is subject, and even health itself till the last fatal struggle of the system 
betrays the lurking and mortal enemy within: sometimes the fits personate dif- 
ferent diseases at different attacks; thus epilepsy in one, pleurisy in the next; at 
other times the fever is subdued, and inteiTnittent affections ; as amaurosis, 
headache, toothache take its place: all these irregularities disappear by the treat- 
ment proper to the fever* as it prevails at that particular season, with some respect 
to the symptoms for the purpose of palliation which appear in particular vital parts, 
when the violence of the action threatens to destroy life before the remedies, as 
the bark, &c. which prevent tlie fit can be given. C. 

FREQUENCY OF PULSE. 

2. The second great feature denoting the presence of fever, is an 
increase in the frequency of the pulse. This is one of the earliest 
and most constant of all the symptoms of fever, and perhaps would 
scarcely ever be wanting, but for some accidental circumstance, 
such as a congestion of the blood in the vessels of the brain. The 
feverish pulse of an adult varies in point of frequency, from the 
slightest increase above the natural standard, to that point at which 
it can with difficulty be numbered.t In forming any judgment ol 
diseases by the frequency of the pulse, great allowance must always 
be made for the age of the patient, — for sex, constitution, and tem- 
perament of body, for the kind and period of the disease, — for ex- 
ternal circumstances; such, for instance, as the state of the air sur- 
rounding the patient, and the irritations to which he is exposed, — 
lastly, for the effect of diet and medicines, and even in some cir- 
cumstances the position of the body. The pulse of fever differs 
from that of health in other points, besides that of comparative 
frequency. These characters of the febrile pulse are distinguished 
by the terms hardness, wiriness, fulness, softness, and weakness; 
but as they are not essential to the existence of fever, they will 
more properly come under consideration hereafter. 

The greater part of our therapeutic views drawn from this source, can only be 
learned by a long and attentive habit of feeling pulses. The sensation imparted to 
the fingers from the pulsation of an artery, is simple and cannot be well defined. 
For some of these sensations, we give names that serve as general marks of dis- 
crimination, but for many of them we want language to express the impressions 
made on our fingers. The epithets hard, soft, frequent, quick, slow, full, large, 
small, weak, strong, regular, irregular, and some others, are so many self-evident 
qualities or conditions "of the state of the circulation ; but the vai'ieties and shades 



* Philip, 61—6. 

-j- For practical purposes it may be advisable for the student to make some rude 
divisions of feverish pulses. The first may have 84 in a minute for its average, and 
may range between the natural standard "and 90. The second may have 100 for it.i 
average, and its range will be from 90 to 110. The third 120, ranging between 
1 10 and l;)2. The last, which I would call the rapid pulse, has 144 for its average. 
It is the kind of pulse which is familiar to all in the last stages o{ hectic fever. 



GENERAL DOCTRINE OF FEVER. 47 

of every one of them are so numerous, that the tactus eruditus of experience may 
divide them almost ad infinitum. The frequency of the pulse is of less importance 
in practice than its hardness, because death is occasioned generally by organic 
injury, and not often by simple irritation or debility. It may be remarked with 
respect to the slowness of the pulse, that it may be occasioned by other causes 
beside cerebral congestion ; probably by direct sympathy between the stomach 
and heart ; such as the presence of worms in the stomach. By certain indigestible 
articles of diet acting on its nerves, and frequently by medicine, the effect of which 
has been received as an indication of a diseased condition of the brain. The long 
continued employment of calomel. The use of antimonials, and the action of 
digitalis, are among tlie examples of slow pulses arising from impressions made 
directly on the stomach. P. 

Of these leading characters of fever, rigor succeeded by heat of 
skin, and increased frequency of pulse, it is curious to observe what 
different judgments have been formed. The bulk of mankind have 
almost uniformly and by common consent, laid the greatest stress 
upon the increased heat of the body, and accordingly all the expres- 
sions for fevei" in different languages are derived from the words 
signifying heat or fire. This was for a long time the doctrine of the 
schools, Galen having taught that the essence of fever was inpraeter- 
natural heat. Boerhaave, who investigated the phenomena of fever 
with great accuracy, and acknowledged the importance of these 
leading symptoms, yet imagined that the quickened pulse was the 
single essential symptom of fever, uniformly present from the 
beginning to the end of the disease, and by which the physician 
judges of its presence and degree. Dr. Cullen, on the other hand, 
placed the rigor and shivering in the first rank of febrile symptoms. 
He imagined that as the hot stage of fever is so constantly preceded 
by the cold stage, the one was caused by the other, and the cause 
of the cold stage, therefore, was the cause of all that followed in the 
course of the paroxysm. These opinions we may be allowed to 
consider as upon a par in point of relative merit. They may all be 
supported by specious arguments, but we must end by confessing, 
that fever does not consist in this^ or that symptom, but in the 
co-existence and succession of many. 

LOSS or MUSCULAR POWER. 

3. Among the various evidences of the presence of fever, the 
loss of muscular power was noticed, marked by the occurrence of 
languor and lassitude, a sensation of fatigue, and great pain referred 
to the muscles and joints, particularly of the back and limbs. This 
striking index of fever was elegantly illustrated by Boerhaave, 
under the title of Debilitas febrilis. It is to be distinguished from 
that weakness of the muscles, which arises from great exertion, the 
privation of nourishment, or the violence, or long continuance of 
an evacuation. It is present in a greater or less degree in all fevers, 
though it bears no proportion to the violence or danger of the dis- 
ease. It is aggravated by the slightest exertions of muscular power, 
and in severe cases is but partially relieved by the horizontal 
posture. 



48 GENERAL DOCTRINE OF FEVER. 

DISTURBANCES IN THE FUNCTIONS OF THE STOMACH, &C. 

4. Disturbances in the functions of animal heat, circulation, and 
muscular motion, afford then the most prominent marks of fever; 
but every other function of the body, animal, vital, and natural, is 
more or less deranged, and that of the stomach in so remarkable a 
degree, as to demand particular notice. Loss of appetite, nmiseoy 
and vomiting, are very common symptoms of fever, but they are 
of secondary importance, both because fever frequently subsists 
without them, and they without fever. Connected with the loss 
of appetite, we may mention the symptom of thirst, one of the 
most familiar of all the characters of fever, and yet one more fre- 
quently wanting than any other. The desire is almost invariably 
for cold drink, and doubtless this is a beautiful provision of nature. 
There is no ground for believing with Asclepiades, and the fol- 
lowers of his school, that any danger is to be apprehended from the 
indulgence of this appetite. 

The restlessness and want of sleep which occur in febrile dis- 
eases are characteristic symptoms which deserve notice. They are 
seldom wanting in the early stages of fever, and are peculiarly dis- 
tressing to the patient, often continuing during the whole course of 
a long fever. The return of sleep is one of the surest indications 
of its decline. 

Nothing more strikingly characterizes the presence of fever, than 
a general diminution and depraved state of the secretions all over 
the body. This is exemplified in the dryness and clamminess of 
the mouth, and the white and furred tongue, which are so fre- 
quently observed in all febrile diseases. The skin is dry and parch- 
ed from the cessation of cuticular transpiration. The urine is scanty 
and high coloured. The bowels are generally constipated. The 
evacuations which may be procured are for the most part dark and 
foetid. These and several other phenomena of fever are referable 
to the important general principle now laid down, 

LEADING DIVISIONS OF FEBRILE DISEASES. 

Having thus explained the characters oi pyrexia, it will be proper 
lo inquire, what are the leading divisions of febrile diseases, and to 
point out generally, what are the chief predisposing and occasional 
(or exciting) causes of fever. 

A very superficial observation of nature is sufficient to point out 
tlie first distinction among feljrile diseases, I mean that into Idio- 
pathic and Symptomatic. Fever is often observed to arise witliout 
any very obvious cause, and tlic j)atient is then said to liave idio- 
pathic fever. When it occurs after an injury, or wlien it is coui)lcd 
with redness of the throat, or acute pain of the side, he is said lo 
have symptomatic fever. It requires a more extended observation 
of the phenomena of disease to remark the leading divisions of 



GENERAL DOCTRINE OF FEVER. 49 

idiopathic fever, which may he considered as threefold. There 
are fevers which consist of paroxysms; there are simple continued 
fevers, and fevers complicated with eruption. In other words, 
idiopathic fevers are divisible into the three great classes of con- 
tinued, INTERMITTENT, and EXANTHEMATOus. Among the symp- 
tomatic fevers which fall under the cognizance of the physician, a 
distinction has been attempted between those which are connected 
with local inflammation, and those attended with ha^morrhagy. It 
is not one of much importance, although I have assumed it as a 
basis of arrangement in this work. 

These are the leading divisions of febrile diseases; but to under- 
stand in what endless varieties they are presented to us, it will be 
sufficient to cast a cursory glance over the great variety of local 
inflammations with which they may be combined, and to reflect on 
the extent of influence, which climate, season, peculiarities of soil, 
age, temperament, and condition of body, may be presumed to 
exert in modifying their symptoms. 

CAUSES OF FEVER, PREDISPOSING AND OCCASIONAL. 

Very little is known with certainty in regard to the predisposi- 
tion to fever. It is observed under aspects the most various. Every 
age, and condition of body is subject to it; it occurs in every variety 
of season and climate; but each of these circumstances modifies its 
character, and contributes to establish those minute shades of dis- 
tinction among febrile diseases which it will be my object hereafter 
to point out and illustrate. It is, however, abundantly obvious, 
that some persons are more liable than others to attacks of fever. 
In common language, their constitutions are more easily lighted up 
into fever. The circumstances which appear more especially to 
give this predisposition to fever are the following: 1, A sanguine 
temperament and irritable habit of body; 2, the period of youth; 
3, depression of mind; 4, peculiar conditions of the atmosphere. 

The exciting causes of fever are very numerous, and apparently 
of very opposite characters. External injuries, irritations of various 
kinds existing within the body, (such as worms;) the free use of 
wine, and exposure to cold and moisture are among the most 
obvious. These have been called by pathologists the common 
causes of fever, in contradistinction to others of a more recondite 
nature which have been termed specific; viz. marsh miasmata, 
contagion, and morbid poison. Much importance is properly 
attached to each of these causes of fever. They open very wide 
fields of inquiry, which, in future chapters, will become the objects 
of separate investigation. 

NATURE OF FEVER. 

It has been a favourite topic of inquiry among all writers on 
fever. What is its nature? — In what particular state of the fluids or 
7 



^^S.'^ GENERAL DOCTRINE OF FEVER. 

"^ ' ■ / /'.'^.. 

solids of the body (Jpes it consist? The subject has been prosecuted 
with great diligence^^ but the result of the investigation is very- 
unsatisfactory. The Earliest opinion on the nature of fever was 
that of Hippocrates, /who imagined it to be a salutary effort of 
nature to throw-^ off some noxious matter; and it is remarkable that 
■^y^-^this opinion :Was(aErtertained before the class of eruptive fevers was 
j^,^ Known, the phenomena of which certainly afford the greatest coun- 
tenanx^e'tb it. The same doctrine was supported by Stahl, who 
acknowledged, however, that when the morbific matter was too 
abundant, or the powers of the body not sufiiciently energetic, 
fevers were hurtful. Boerhaave assumed as the essence or proximate 
cause of fever, a lentor, or viscid state of the blood, and he applied 
this principle very ingeniously to the explanation of the phenomena 
of fever. 

The most rational views of the intimate nature of fever are those 
of Hoffman, who believed that fever consisted primarily in dimin- 
ished energy of the nervous system. Without following this 
author through the minute explanation of the several symptoms of 
fever which he founded upon this doctrine, we may be permitted 
to say, that as a general principle it is fairly admissible, and that it 
satisfactorily accounts for many of the first and most characteristic 
among them. Dr. Cullen went a step f\irther, and argued that the 
diminished energy of the brain brought on spasm of the extreme 
vessels, which spasm was the resil proximate cause of fever. Since 
Dr. Cullen's time there have been several ingenious attempts to 
explain the pathology of fever. Dr. Wilson Philip supports the 
doctrine that fever consists, not in a spasm of the extreme vessels, 
but in the praeternatural distension, and consequent debility of the 
capillaries. * 

All of these theories are open to many and strong objections. 
An insuperable difficulty indeed seems to hang over the pathology 
of fever, t but it is fortunately of little moment. No theory of the 
proximate cause of fever which has yet appeared has contributed in 
any material degree to improve the treatment; though several of 
them, especially the Hippocratic, have had the effect of misleading 
and confusing the practitioner. The phenomena of fever give 
evidence of diminished energy of the brain, with increased action 
of the heart and arterial system; and the difficulty in the pathology 

* Others refer the source of fever to the inflammation of some particular organ, 
or org-iins ; as, Bianchi to the Liver — Swalve to the pancreas — others to the vena 
cava — Uahn to tlie dig-estive function s^cntrally, and Broussais to the mucous 
membrane hning- the intestines ; and finally Cluttcrbuck to the brain ;t as no facts 
are adduced by the advocates of these doctrines to show that the local affections 
preceded the fever, which they should do, if they were its ca\iscs, and as there are 
many fevers in which there is no inflammation, nor local aflcction of any kind 
whatever they necessarily ftdl to the gTound. C. 

f Febris, si ph.cnomena illius spectes, relicjuismorbis est notior ; si constitutioncm 
• et causam onnii\mi ig-iujlissima. — liAfiLivi de Praxi Medica, cap. xiii. sect. 5. 

; (i(i.uJ\ Sdidy ufMi'ilicino. p. -ir. vol. ii. 



GENERAL DOCTRINE OF FEVER. 51 

of fever consists in showing, in wliat manner these disturbances of 
function are connected with each other. Tlie older pathologists 
supposed it was brought about by the vis medicatrix naturae, for 
which in modern times we have substituted the principle of re- 
action; but the precise mode in which this re-action of the heart 
and arteries is effected, appears to be altogether inscrutable. 

To the diminished energy of tlie nervous system we ascribe the 
languor, lassitude, loss of appetite, general uneasiness and pain in 
the back, which mark the invasion of fever. The functions of the 
brain not being as )^et thoroughly understood, it is doubtful whether 
or not we are authorized in attributing to the same source, the 
diminished and depraved secretion which occurs in fever; but it is 
highly probable, that the phenomenon is in some measure connected 
with it. The same thing may be said of the increased heat which 
attends fever, the physiology of animal heat being, like that of 
secretion, involved in much obscurity. It would appear, however, 
that this is a mixed function, in which the brain and heart are both 
essentially concerned. 

The pathology of the fluids has been too generally overlooked by the medical 
world, in the examination of the phenomena of tlie system during- fever. The expe- 
riments and observations made of late years, place the blood in a conspicuous point 
of view in the history of these diseases. It is not however to the humoral pathology 
of the ancients, that we are to look for a rational explanation of their phenomena ; 
with them, the state of the fluids was brought into the philosophy of the system, 
conveyed under terms which had no meaning, and which were neither understood 
by their inventors, nor those they pretended to instruct. Dissatisfied with its 
insufficiency, the opinions of medical men took the opposite extreme, and from 
believing that the fluids were the most general causes of morbid phenomena, they 
ascribed every thing to the solids, and discarded the humoral pathology as an 
absurdity : at present, the more judicious part of the medical world beheve, that its 
entire abandonment has been prejudicial, by leading the mind "from the exami- 
nation of the various morbid states of the fluids and the best means fitted to correct 
them."* 

In our own country, Drs. Hosack and Eberle have turned their attention to this 
subject; and from the facts and views adduced by them, they have contributed 
much to bring into notice the extensive eflTects which the fluids produce in the 
system. " Whether," says Dr. Eberle, "we regard the blood as a vital or dead 
fluid, its constant influence upon the various organs of the living system is unques- 
tionable. For, a material which, like the blood, constantly moves through the 
system and penetrates every fibre ; which acquires certain qualities, and loses them 
again in its circuit through the body 5 which, in fine, conveys the elements of all our 
secretions, and keeps in play the very fountain of life — the heart; must, it is obvious, 
produce a constant though imperceptible impression upon the whole organization. 
As long as the blood retains its health}^ condition, the impressions must be com- 
patible with the healthy performance of the organic functions of the animal 
economy. A change in its natural constitution, it is reasonable to conclude, must 
be followed by a corresponding alteration in its general influence upon the system. 
Thus, when it is not duly decarbonated in the lungs, the brain, together with the 
functions that depend on it, become torpid ; and hence it appears, that a certain 
condition of the blood, depending on the absence or presence of certain matters, is 
indispensable to the regular performance of organic action." On this subject, 
modern experiment has accumulated too many facts, not to place the doctrine of 



Armstrong on Typhus Fever, p. 120. Am. Ed. 



52 GENERAL DOCTRINE OF FEVER. 

the pathology of the fluids on the basis of absolute certainty. It is indispensable 
to a proper knowledg-e of the diseased phenomena of the system: "and more par- 
ticularly," as Dr. Hosack observes, *' the recent experiments of Sir Everard Home, 
relating- to the operation of medicines upon the body tlu-ough the medium of the 
fluids; the communication of diseases from one animal to another by transfusion, 
as lately performed by Mr. Coleman, at the veterinary school of London ; the 
transmission of disease from the mother to the fcEtus in utcro ; the analysis of the 
fluids both circulating and secreted ; the chemical examination of the products of 
the body, as occurring- in various diseases have recently, both in Europe and 
America, directed the attention of physicians to this neglected part of the human 
pathology,"* and forced upon us the conclusion that the part performed by the 
fluids is one of primary importance in all its functions. The experiments of Harlan, 
Coates, and Lawrence, also are very decided on this point; they go so far as to show 
that medicines are absorbed into the blood, and that when admitted there, they 
are even decomposed in that fluid, by a play of affinities. With regard to the 
absorption of medicines into the blood, as also the pathology of certain diseases, 
explicable on those pnnciples, we refer to the Essay of Dr. Eberle, in the Medical 
Recorder, for many valuable observations. f C. 

Febrile thirst is a symptom which has never been satisfactorily 
accounted for. The restlessness, head-ach, delirium, and other 
disturbances of the animal functions which occur in fever, are cer- 
tainly attributable to an increased flow of blood upon the delicate 
structure of the brain. They neither depend upon inflammation, 
as some have contended, nor upon debility. They are neither 
connected with actual congestion within the brain, nor are they 
referable to sympathy of that organ with the chylopoietic viscera, 
as others have imagined. 

The hypothesis that the phenomena of fever are owing to diminished energy of 
the nervous power, is equally incapable of demonstration: To suppose that the 
cause of fever acts solely on the nervous power, is entirely g-ratuitous: The nerves 
and blood-vessels penetrate every part of the body so completely, that if cither 
system were removed, its form and sliape would be represented by the other 
which remained. To suppose, then, that the morbific particles act upon either 
independently of the other, is a point which cannot be proved, nor admitted into a 
system of correct medical principles, without the necessary preliminary to all 
scientific truth — absolute and indisputable demonstration. What theory is then to 
be admitted? To this we answer, that the human body, like all others, is capable of 
being acted upon by physical agents, and the effects, not the mode of their opera- 
tion, are knov/n, and the senses are tlie instruments by which we are apprized of 
them. As these instruments discover only certain phenomena, without apprizing- us 
of the subtle changes which the system undergoes, and by which they arc produced, 
all we can say, is, that the phenomena are all we know, and that the true philo- 
sophy of medicine is to describe their successions, with the means of their preven- 
tion and cure: This it can do; but it can do no more: as in natural philosophy, it 
is impossible to determine the nature of gravity on which hang- the laws of that 
science; so in medicine, the intimate properties of life are equally inscrutable; the 
effects of the principle upon other bodies, and of other bodies upon it are all we 
know; we therefore think tlie ideas of Fordyce, contained in the following- words, 
present a true view of the subject of fever, and one, wliich is free from hypothesis 
and consistent with the best philosophy. 

Fever is a disease which affects the whole system; it affects the head, the trunk 
andtlie extremities; the circulation, absorption, and the nervous system; it affects 



* See Hosack's Essays, vol. ii. p. 92. 

f On the Humoral Pathology, vol. v. Med. Recorder; Dyckmun's Essay, and the 
Pliiladclphia Journal of the Med. &, Phys. Sciences. 



GENERAL DOCTRINE OF FEVER. 53 

the muscles and the membranes; it affects the body and likewise the mind. It is 
therefore a disease of the whole system, which, however, it affects unequally; at 
sometimes one part; at others, another, &c.* C. 

PERIODIC MOVEMENTS IN FEVER. 

Many of the phenomena of fever, its progress, and termination, 
appear to be guided by one of those laws of the animal economy, 
the influence of which is sufficiently manifest in a state of health — 
I mean the principle of periodic movement. The most obvious 
illustration of this which physiology affords, is in the periods of 
utero-gestation and menstruation ; but the recurrence of our appetites, 
the disposition to motion, sleep, and waking, and, in many, the 
natural evacuations, are phenomena regulated also by a principle of 
periodic movement. The regularity observable in the periods of 
the eruptive fevers, of which we shall hereafter speak more fully, 
is unquestionably the most beautiful and well-marked illustration 
of the same thing which pathology affords; but it is exemplified also 
in some of the phenomena of gout, mania, epilepsy, and menor- 
rhagia. To this principle of periodic movement in the animal 
economy have been ascribed the types of intermittent, and the 
crises of continued fevers. Of the former we shall treat more fully 
hereafter. What is essential to be known concerning the latter, 
may find its place here. 

The doctrine of critical days in fever, that is to say, the suppo- 
sition that febrile diseases are disposed to terminate favourably or 
unfavourably at certain periods of the disease more than at others, 
has found many advocates, and some opposers, even from the 
earliest times. The very general reception which it has met with 
among mankind, makes me unwilling to distrust it altogether; and 
if we bear in mind how many circumstances may contribute to 
disturb the regular course of the disease, we may admit the doctrine 
of critical days in fever without much risk of error. There has 
been some dispute about the precise days, but they are generally 
set down as the seventh, ninth, eleventh, fourteenth, seventeenth, 
and twenty-first, counting from the invasion of the cold fit. During 
the first week of fever no days of crisis can be ascertained. In the 
second week it happens on the alternate odd days, and the three 
first are therefore called the tertian crises. In the third week, the 
critical days follow the quartan type, and the three last are therefore 
called the quartan crises. It is seldom that these observations can 
be verified in the fevers of this country, which run their course 
with much less regularity than those of warmer climates. 

The last illustration of that principle of periodic movement 



* Good's Study, Sec. p. 42. vol. ii. The above is the substance of his views, and 
nearly his words. They express simply the history of the phenomena and their 
successions, and not the vagaries of the imagination. C, 



54 GENERAL DOCTRINE OF FEVER. 

observable in the diseased actions of the body, which I shall now 
notice, is the disposition in all febrile diseases whatever, to evening 
exacerbation and morning remission. This is strikingly manifested 
in hectic and infantile fever; but it is equally to be traced in all 
the more common forms of continued fever. Severe as the symp- 
toms may have been during the day, they will generally be found 
aggravated about six or seven o'clock in the evening. Restless as the 
patient may have been during the night, he \vill generally obtain 
some rest, or relief from his complaints, soon after daylight. These 
circumstances are important in reference to the proper period for 
the exhibition of medicines. 

PRINCIPLES or TREATMENT IN FEVER. 

A few general remarks on the principles which should regulate 
our treatment of idiopathic febrile diseases, will conclude what is to 
be said regarding the general doctrine of fever. 

1. The most important feature in this view of the subject is, the 
natural tendency in all febrile diseases to run a certain course, and 
to terminate in the restoration of health. It is this circumstance 
which forms so prominent a distinction bet"ween acute and chronic 
disorders. It is observable in many local affections attended with 
fever, but it is very strikingly illustrated in the case of continued 
fevers, and the exanthemata. The latter will always, and the 
former will very frequently, run their regular course, in spite of all 
the efforts of art. In ancient times, nay even at no very distant 
date, it was made a question, whether it was safe and proper to cut 
short a fever. The question is set at rest with regard to the j^to- 
priety of doing so, but the possibility of it is still very questionable. 
It may sometimes be practicable, but it can never become the foun- 
dation of our treatment in febrile diseases. The natural tendency 
of fever to come to a crisis, or to work its own cure, may, on the 
other hand, be often kept in view with the best advantage; and 
though the extravagancies of a inedicine expeciante are justly 
blameable, the spirit of the doctrine should never be disregarded. 

The idea lliat fever cannot be cut short, is one which in g-eneral is advocated by 
feeble practitioners; l)y men who are averse to all energ-etic measures, and who 
desire rather to continue in the beaten track, than to advance the science by judi- 
cious measures. How soon may be tlie natural termination of a fever; whether in 
one fit, two, three, or ten, it is impossible to decide; it is therefore absurd to let the 
more or less speedy prospect of its future termination have any thing- to do with 
our measures, except so far as the fever must at every moment be considered as a 
noxious cause, which is necessary to be removed as soon as possible. The ordinary 
remittent and typhus fever of hot climates have been cut short by mercury, which, 
as soon as it bcg-ins to act upon the gums, often has this effect; cold water thrown 
on the surface has stopped at once common fevers; and even the yellow fever has 
been cured, by the excessive and profuse evacuations of bleeding- and perspiration. 
The advancement of a doctrine that fevers cannot be cut sliorl in their course, and 
in every stage of it, is one that is not entirely true; and, as it tends to paralyse the 
4)urs\iit of new and useful truths, should not be held up in such strong language by 



GENERAL DOCTRINE OF FEVER. 55 

the author. The quartan type of intermittent was once considered as incurable ^ 
now it is not more so than other forms: the drojjsy was once viewed in the same 
hg-ht, but it is now, except where the constitution is worn out, considered as a 
disease which is often cured. Fever is a disease wliich ])resents a certain combi- 
nation of symptoms, that conspire to destroy hfe; and the practitioner should only 
have in view, their removal by the apphcation of sucli physical means, as are suited 
to this purpose, without regarding- what may be the disease some days hence, but 
what it is now. This observation applies most particularly to highly inflammatory 
pleurisy, and other phlegmasise in robust habits; bleeding- as long- as there is any 
pain cuts it short; without it, it is protracted or the patient dies of abscess: the 
same is true of the inflammation which follows extensive wounds; as after the 
operation for the stone: bleeding- till the pain is removed, and repeated as often as 
it returns, cuts short the reaction and perfects the cure. This is true not only of 
acute but of chronic diseases: the application of the proper medicine at once cuts 
them short, whereas procrastination confirms the diseased habit, streng-thens the 
causes and increases the difficulty of the cure. Nil desperandum should be the 
motto of every man eng-ag-ed in the practical duties of life, particularly in a profes- 
sion on which so much depends as that of medicine. C. 

2. We might la)^ infinitely more stress on this principle in the 
general treatment of fever, and act up to it with much more free- 
dom, were it not that a second interferes with it, of at least equal 
importance, but leading to a practice diametrically opposite. This 
is, the disposition which exists in all febrile states of the system to 
local congestions and inflammations, and irregular distributions of 
blood, which end in very serious disturbance of function, or actual 
disorganization of structure. Such a principle appears to have been 
overlooked by several of the old school of medicine, or at least 
never to have attracted that attention, which its importance in 
practice merits. It shows the necessity of using every endeavour 
to cut the fever short, before such local congestions or inflammations 
have taken place, or at any rate before they have attained any 
dangerous height. 

3. The third point which I think of importance in regulating the 
treatment of fever, is the necessity of studying symptoms and of 
deducing from them the indications of cure. The pathology of 
fever is so obscure, that it afibrds but little help in determining the 
plan of treatment. In many diseases, apoplexy for example, or 
dropsy, individual symptoms are of little practical importance, for 
we treat them by a consideration of their cause: but in fever the 
alleviation of particular systems is often a matter of the highest 
importance. The variations too in the symptoms of a fever are 
often great and rapid; and with them must vary our views of the 
actual condition of the body, and consequently the plan of our 
treatment. It will be seen hereafter, that this point of doctrine 
applies to all the forms of idiopathic fever. 

As to the obscurity of the pathology of fever it is not more so, than any othei- 
subject of physical science. The symptoms are the only subjects of observation 
cognizable by the senses; they are the phenomena, by which we judge of die 
nature of the subject; and in proportion as we know them accurately, extensively 
and minutely, so in proportion do we know the nature of fever: the body is known 
only by the qualities it presents to the external senses, and just in the same manner 
as the subjects of natural philosophy are; and it is, in a rational view of the subject. 



56 GENERAL DOCTRINE OF FEVER. 

as absurd to pretend to discover the nature of fever or its pathology, by any other 
mode than by the examination of its symptoms or qualities, as it is to discover the 
nature of gravity without studying- the phenomena: there is a mystery behind the 
phenomena in both cases, and there ever will be, as long as the human mind is so 
weak as to indulge itself in looking farther than the appearances, wliich each 
exhibits to the senses. The idea that there is in every physical subject an essence, 
or subtle something, round which the phenomena are aggregated, is the source of 
this en-or: It led to the absurd speculations on the subject of gravity before the time 
of Newton, as it does now to those upon fever; which, like gravity, is only to be 
known by its qualities or symptoms. To prescribe for any thing else is to prescribe 
for a word — viz. fever; an error which the author has committed in his views with 
regard to apoplexy and dropsy, which he seems to regard as independent and 
immutable essences, to be treated in the same way, under all circumstances; how- 
ever, like all other subjects of medical enterprise, they vary, and we know this, 
because their symptoms and characters vary, and as also the results of treatment in 
different modes; thus, dropsy during the prevalence of an inflammatory atmo- 
spheric constitution is known to require bleeding, which in general it does not; 
apoplexy sometimes requires stimulation; often, bleeding; sometimes it is attended 
with a general warmth of the skin and whole body; at others coldness of the feet; 
to restore the warmth of which constitutes an essential part of the treatment, and 
is a successful means both of its prevention and removal; whereas, when the skin 
and feet are warm, it of course is not so. The view which regards fever as an 
independent existence, or its pathology as a subtle essence, is as great an absurdity 
in philosophy, as the belief in ghosts or fairies, or any other imagination of the 
human mind; which neither knows nothing, nor has a rig-ht in true philosophy to 
conceive any thing of the external world, but what is derived from the senses. C. 

4. The necessity of attention to the nature of the prevaih'ng 
ejndemic is the last point which I would urge. Epidemic diseases 
are with very few exceptions febrile; and it is a curious but well 
ascertained fact, that the epidemics of particular seasons acquire a 
particular character, the knowledge of which assists very materially 
in forming a judgment as to the treatment proper to be pursued in 
any individual case. Sydenham was among the first authors who 
directed their attention to the epidemic character of seasons. He 
pointed out, not only that diiScrent febrile diseases prevailed in 
different years, but that the same form of febrile diseases assumed 
in different years different characters, and required corresponding 
changes of treatment. This important doctrine might be illustrated, 
not only by the phenomena of continued fevers, whose characters 
are so infmitcly varied, but by those also of agu<;s, and the inflam- 
matory affections of the thorax and abdomen. The principle is 
observable even in the phenomena of eruptive fevers, such as small- 
pox and measles, which are but little modified by the influence of 
other causes. 

This is true not only with regard to fevers, but to all other diseases during the 
prevalence of an epidemic: thus Stoll found that dropsy and abortion required 
depletion as well as the prevailing fevers and inflammations; the constitution of 
the year is necessary to be known, in order that the remedies may be given of a 
strength :ulapted to the force of the disease, that weak medioincs m:iy not be given 
when strong arc required, and Vice versa. It lias Ijccn believed th:it more f:iith is 
to be i)ut in :i knowledge of the i);u"ticular plan of treatment ;id:ipted to each 
epidemic, c:illcd a knowledge of the constitution of the year, derived from practice, 
than by attention to the particular symptoms of the diseases we are called to treat; 
' and this really appcai-s to be true, as all diseases partake of the nature of the 



GENERAL DOCTRINE OF FEVER. 57 

reigning epidemic; catarrhs, abortions, hemorrhag-jes, rheumatism, in the epidemic 
of 1788 at Vienna were treated in the same way; in the yellow fever of 1793, the 
same was true; all diseases in the whole range of sea, island, and land, north of the 
line, during that year were cured in the same way; depletion was the sovereign 
remedy. In the year 1813-14 typhus prevailed to an alarming degree in the 
United States; stimulation then was the only means of cure, and many died, 
whatever might be their disease, who were treated by any other plan. 

These reflections show the necessity of perfect unanimity and harmony among 
medical men, in order that by a free intercourse they may inform each other of 
the results of their experience, and the nature of the prevailing epidemic; which 
can be discovered only by practice, and not by symptoms; these, however, regulate 
the force of remedies after the general plan is determined from observing the 
diseases of the pecuhar constitution. C. 



( 58 ) 



CHAPTER 11. 

TARIETIES AND SYMPTOMS OF CONTINUED FEVER. 



Nosological Divisions of continued Fever — Circumstances mo- 
difying the Symptoms of continued Fever; Climate and 
Season; the State of the Air; Constitution and Habit of 
Body — Symptoms of Inflammatory Fever — Of common con- 
tinued Fever — Of Typhus — Of Fever complicated ivith local 
tMffection — Causes of such Complication — Of the Organs and 
Strictures affected in the Course of Fever — Nature of the 
local Affection — Morbid Appearances from continued Fever 
— Period of Fever at which local determinations take place — 
State of Oppression in Fever — Principles of Prognosis — Of 
Malignancy and Putrescency — Favourable Symptoms — Aver- 
age mortality by continued Fever. 

NOSOLOGICAL DIVISIONS OF CONTINUED FEVER. 

Idiopathic Fever was stated in the last chapter to admit of a 
three-fold division; viz. into intermittent, continued, and eruptive 
fevers. We shall begin by the consideration of continued fevers, 
and in the present chapter shall confine our attention to the various 
appearances which they exhibit. 

The views of physicians with regard to continued fevers have 
undergone a number of very remarkable changes, to which nothing 
has more essentially contributed, than the infinite diversity of 
symptoms by which they are characterized. Nosologists have been 
at great pains to note minutely these different symptoms, and have 
founded upon them their divisions of continued fever. Boerhaave 
has three, Linnaeus four, Sauvages five, and Macbride fivc-and- 
twenty species of continued fever. Some have assumed, as the basis 
of their arrangement, the comparative duration of the disease; but 
the generality of authors have made the difference of symptoms the 
ground-work of their distinctions. From the very earliest periods 
it was observed, that some fevers showed symptoms of strong in- 
flammatory action, while others exhibited marks of depressed ner- 
vous energy, and, as it was said, of putrescency. One of the first 
distinctions therefore among fevers was into i\\efcbris ardens and 



VARIETIES AND SYMPTOMS, 8cc. 59 

the febris putrida. There being however a variety of fevers, 
which showed first the one, and then the other of these sets of 
symptoms, nosologists added a third class, or that of mixed fevers. 
Such is the arrangement of Dr. Cullen ; and the terms Synocha, 
Typhus, and Synochus, were employed by him to express these 
fundamental divisions of continued fever. 

Of late years, a different view of the varieties of continued fever 
has been gradually gaining ground. An increased importance is 
attached to the exciting cause, and the term typhus is now re- 
stricted to a particular form of continued fever, which we shall 
presently describe; one of the distinguishing features of which is, 
that it is communicable by contagion. To the other varieties of 
fever, arising from cold or irritations, we apply the term common 
continued. 

A third important distinction among continued fevers is now 
derived from the circumstance of their affecting all organs and 
functions equally, when they are called sim^ple fevers, or implicat- 
ing one organ or structure more particularly than another, and 
deriving from it some peculiarity of character. Fevers of the latter 
class are infinitely diversified, and have received the several deno- 
minations of brain fever, catarrhal fever, gastric, mesenteric fever, 
miliary fever, bilious fever. These distinctions among fevers, 
though apparently vague, are yet sufficient for all practical purposes. 
They do not withdraw the mind from the important consideration, 
that the nosological divisions of fever are arbitrary, and calculated, 
not to direct the method of cure, but to increase the facility of 
instruction. 

CIRCUMSTANCES MODIFYING THE SYMPTOMS OF CONTINUED FEVER. 

Continued fevers have all a common character, but various cir- 
cumstances serve in a remarkable manner to modify it. What 
these are, and the extent of their influence, is a subject worthy of 
accurate investigation. 



CLIMATE AND SEASON. 

1. The most important of them all is climate. Its effects upon 
the general character of man, the structure of his body, his stature, 
his intellectual faculties, his habits, and dispositions, it is the pro- 
vince of the physiologist, the natural historian, and the political 
oeconomist, to unfold. Its influence upon the morbid conditions of 
the body, we shall have frequent opportunities of illustrating. We 
shall see it exemplified in the phenomena of hepatitis, gout, scro- 
fula, dysentery. Of all states of disease, as fever is the most gene- 
ral, so is it that, over which climate has the greatest modifying 
influence. The important principle to be kept in view is, that a 
hot climate is favourable to the developement of inflammatory fever; 



60 VARIETIES AND SYMPTOMS 

while the low, or nervous form of fever prevails chiefly in colder 
or temperate climates. 

2. Season may be considered as modifying the character of con- 
tinued fever much in the same manner as climate. The spring and 
summer seasons favour the prevalence of inflammatory fever; 
autumn and winter of the putrid or nervous fever. Warm climates 
and seasons give a tendency to complications of abdominal disease 
with fever; cold climates and seasons, on the other hand, to affec- 
tions of the thoracic viscera. The evidences of this point of doc- 
trine will appear when we come to treat of the diseases of particu- 
lar organs. 

These remarks of the author, thoug-h short, are of the greatest Importance ; thus 
the spring, owing to the heat succeeding the cold of winter, makes remittents 
inflammatory and dangerous ; the autumn, on the contrary, from the reduction of 
temperature, after the heat of summer, renders them tedious. Dry cold weather 
from the north, from its inflammatory tendency, makes agues regular in their 
type, and at the same time renders V. S. proper. On the contrary, moist weather 
with a southerly wind, makes them tedious, typhous, and malignant : by thus 
appreciating the general effects of the sensible qualities of the air upon the body, 
we are assisted in forming an accurate prognosis directing the proper treatment of 
these diseases. If a cold dry wind prevails for some time, diluents will be more 
proper, and a less stimulating treatment than if the weather be cold and moist, in 
which latter case the bark and other tonics and stimulants are useful. The influ- 
ence of the weather upon the type of diseases in this country, is not believed, as 
regards the changes which take place in short intervals of time, as from week to 
week, though on a larger scale, as when the diseases of winter are compared with 
those of summer it is ; when those of the countries near the equator are compared 
with those in the north, they are acknowledged to be different ,• and as they are 
so, it is rather astonishing, that the effect of the A\'eather on the character of dis- 
eases, in short spaces of time, should not be more regarded: thus, in typhus, the 
effect of the tonic qualities of the air are observed ; but, in intermittents, diseases, 
which many practitioners think they can cure without difficulty, it is not sus- 
pected, when the current train of symptoms in an individual case is taken into 
view. It is by appreciating* the effects of these agents of a general nature, by com- 
bining their influence in a scientific and accurate manner, that the profession of 
medicine is rendered useful. It was an observation of Stoll, of Vienna, that a phy- 
sician, who did not observe the influence of the weather upon the S3'stem, could 
not practice with safety to his patients ; and that it was as necessai-y to be attended 
to, as the syniptoms of every case. 

Habit has great effect in regulating the effect of morbid causes ; thus the inha- 
bitants of northern climates become sick on going to the south, and the reverse ; 
a person accustomed to lying in bed for a long time, feels no inconvenience from 
it ; one who is not, is thrown into fever, more particularly if confined to one pos- 
ture, and that an awkward one ; on this account, previously to performing opera- 
tions, confinement for some time in the posture in w hich the patient is to lie after 
the operation, prevents fever. 

Inhabitants of wet countries are more susceptible of the diseases produced by 
dryness, and vice versa. It applies to all the causes which operate upon the 
system. Pringle relates, that in the ai-my on taking the field in the spring, 
the sick increased, for the first month, in numbers considerably, but that after- 
/ wards they regularly decreased,* from the influence of habit. There is in every 
cause, which is necessaiy to the system, a medium degree, in which its effect is 
most salutary : thus, between 50 and 60 with regard to temperature ^ the state of 
the air produced in a country gently undulated and rolling, (if no large body of 
water is near,) four or five hundred feet above the level of the surrounding 



Pringle, Rush's, p. 103. 



OF CONTINUED FEVER. 61 

country, or liigher, if the ocean or much water is near, furnislies about the proper 
medium with regard to moisture : air at that licight invigorates even invalids, 
whose sensibihty is accumulated, to so morbid a degree, as to be able to fore- 
tell all its changes, with regard to moisture, five or six hours before they take 
place, and who are so sensible to cold, as to feci the difference of efiect produced 
by the depression of temperature a few degrees below 75° or 80° of P'ahrenheit, 
which to them is the comfortable temperature. To all persons the elevation of 
about four hundred feet above the surrounding country is healthy, and even within 
the tropics pleasant ; at the height of six hundred it is more so ; at the height 
of from fourteen to fifteen hundred it is observed that people live to a great 
age ; above that height even within the tropics, it becomes damp and raw, and 
the people are subject to inflammatory diseases, as in northern latitudes ; in 
higher situations these diseases increase, till scurvy, on very high elevations, as 
Pinchincha in Peru, appears, and the system becomes as incapable of supporting 
it* as in low, marshy, or other very moist places. It is this medium, which as a pre- 
ventive and curative mean, the physician must always have in view, and it is by 
the deviations from it r that the efiect of the sensible qualities of the air, in the 
various seasons, climates, and latitudes, are to be estimated. 

To show the effect of climate and season, moisture and heat, &c. upon fevers, 
we shall go a little into detail : 

A low temperature produces simple inflammatory fevers and inflammations ; as 
it rises above the temperate point, intermittents of the tertian form appear with 
slight bilious discharges ; they become quotidian, and at last remittent, as the 
summer advances ; remittents with their visceral complications increase with the 
heat, become malignant, and at last, as it moderates, agues in northern and cold 
chmates, appear in the quartan form, or more to the south, in the tertian ; remit- 
tents, from inflammatory, becoming typhus at the same time ; all of which, though 
obstinate, are less dangerous. The intestinal varieties of summer diseases, also 
observe a particular order ; dysentery and diarrhoea are most common in wet and 
changeable seasons, and also in the autumn, when the days are hot and stifling, 
and the nights cool i (we speak now of southern latitudes.) Heat alternating with 
cold from any cause, favours the production of these diseases. Cholic and cholera 
appear early, as the first eflTect of sudden heat ; in children, whose systems are 
weaker, it is always the result of the first hot weather, particularly in cities, and 
continues generally throughout the summer. In India it becomes epidemic from 
the excessive heat ; however, in some seasons diarrhoea and dysentery prevail 
early, and in others they are not seen. In some neighbourhoods the intestinal forms 
are more common, in others, fevers ; they both appear in places where animal and 
vegetable putrefaction is greatest ; or where from the use of improper food, as 
damaged flour, (which sometimes occurs in cases where the supply is general and 
difficult, as in armies,) or acid fruits, or ripe fruit taken in enormous quantities, 
which by weakening the bowels predispose to these diseases. Sometimes sudden 
changes of the air from unseasonable heat to cold, also produce this last variety in 
the spring ; exposure to the air in tents and lying on the cold ground, produces it 
in armies ; diarrhoea and griping pains arise from the same causes ; in the same 
manner great heat early in the spring introduces choleras, cholics, and remittents, 
sooner than usual ; its effect is increased by dryness of the air to a certain extent 
consistent with putrefaction ; whilst refreshing showers postpone the appearance 
of summer diseases till a later period. The same causes also which hasten or post- 
pone these diseases, render them more intense or more mild ; an excessively dry 
and hot season rendered the remittents of Pennsylvania and Ohio, in the summer 
of 1822, typhoid and excessively mortal ; the south wind also increases their malig- 
nity and danger in dry and hot seasons ; the dews supplying the moisture, by 
which putrefaction, the source of these fevers, is produced. But if the showers, 
instead of being refreshing, are excessive, from their combination with excessive 
heat, great mortality is the result ^ if the showers cool the air, the disease ceases ; 
if it be merely moist without showers, it increases it. Relapses are then more fre- 
quent from the power of their causes, which declines as the autumn advances, till 



Bouguer Mem. de TAcad. Royal, des Sciences, 1744. 



62 VARIETIES AND SYMPTOMS > 

the frost appears, when it is entirely lost. In the ensuing spring these diseases 
again recur, with their consequences, obstructions of the liver, spleen, dropsy, and 
tympanites. The winds also have an effect, according to their temperature ; north 
and northwest winds, in the United States, prevailing in the spring, will prolong 
the inflammatory diseases and agues of that season, and delay the appearance of 
the summer fevers ; whilst winds from the same quarter, in the summer, are cool, 
dry, and healthy, because they dispel the vapours, produce a clear sky and a pure 
invigorating atmosphere ] they render the remittents milder, when they are dis- 
posed to become malignant, and if they continue long, they suspend these diseases 
altogether. If, however, the winds from the northeast and east prevail, and the 
summer be cold and wet, the remittents sink into the typhoid form. Quotidians 
become tertian from the same cause ; from tertian they become quartan, and sink 
into dropsy and nervous diseases. Relapses are frequent during wet seasons. These 
observations, though made in a northern latitude, apply to all climates; such is the 
effect of habit on the constitution, that the vicissitudes of the weather from hot to 
cold in the south, though slight, are as much felt as in the north, so sensible is the 
system : thus, even death from exposure to cold, sometimes occurs in the winters 
of Carolina ; further, the yellow fever has appeared at Copenhagan in an exces- 
sively hot summer, from the effect of the generally low temperature of the climate. 
The diseases of Guinea are mild among the natives, whilst among foreigners from 
a northern climate visiting that region, they are horrible, and produce death in a 
few hours. In autumn the north wind produces the same effects ; it is always 
refreshing and salutary. From the north and east on this side of the Atlantic, after 
the great heats are over, it introduces the intermittent form, and when it appears 
suddenly, produces the dysentery. The prevalence of winds from the south in the 
spring, hasten the early appearance of the remittents of summer, with their atten- 
dant varieties — cholera, cholic, diarrhoea, dysentery, and hepatitis ; and increases 
their danger. This is true of the continent of Europe as well as of the United 
States ; when the wind veers to points east or west of south, the Atlantic or Pacific 
oceans fui*nish vapours, which, borne over this great continent, dispel the inflamma- 
tory diseases of spring; and if they continue, the intermittents of that season are 
changed into remittents, and gradually, as the summer advances, assume a malig- 
nant character, because they favour putrefaction by their heat and moisture. Re- 
lapses are more frequent during the prevalence of these winds ; they affect, also, 
the respiration and depress the spirits. The routine of these diseases, as stated 
above, is the result of the alternation of temperature ; the winds, according as they 
increase or diminish the temperature, hasten or retard these diseases in their suc- 
cession, or abate them in their violence ; cold in summer abating the forms peculiar 
to that season, in spring and autumn approximating them to those of winter ; whilst 
the diseases of winter are moderated by the increase of temperature, and are made 
to resemble those of spring or autumn. These remarks explain the effect of 
latitude on diseases. C. 



THE STATE OF THE AIR. 

3. The next of those circumstances which strikingly modify the 
symptoms of continued fever, is the condition of the air. The 
influence of the atmosphere on febrile diseases is a subject that opens 
a very wide and difficult field of investigation. It appears, that of 
those states of the air which affect the origin, diffusion, progress, 
and character of fever, some are obvious to our senses, and some 
not. Sydenham has described these under the appropriate desig- 
nations of the tcmpcries aeris manifesta, and occulta. The con- 
dition of the air, in regard to heat and cold, dryness and moisture, 
must obviously exert an important influence; but it has further been 
always observed, that the most dangerous fevers are those which 
prevail, where the atmosphere, in its chemical composition, is 



OF CONTINUED FEVER. 63 

impure from the neglect of proper ventilation. Sucii a vitiated 
state of the air (very liable to occur in camps, jails, ships, crowded 
and small apartments) gives occasion to those symptoms which are 
called low or putrid; while, on the other hand, a free circulation 
of cool and pure air conduces to the developement of those which 
are now generally called the symptoms of excitement. This is 
sometimes exemplified in a remarkable manner, in the sudden 
removal of a patient labouring under continued fever from an impure 
atmosphere into the spacious wards of a well-regulated hospital. 
The symptoms have under such circumstances been observed to 
alter very materially, and the constitution to undergo such a change, 
as to require, and to enable the practitioner to carry into effect, 
measures which were previously inadmissible. But besides those 
obvious qualities of the air which modify the symptoms of fever, 
there are certain others, undiscoverable by any of our senses, which 
appear to have great influence over them. A few conjectures have 
been hazarded by Sydenham and others, with the view of throwing 
some light on the nature of these occult qualities of the air; but the 
subject is involved in a degree of obscurity, which will probably 
for ever continue to baffle our researches. Their existence, how- 
ever, can hardly be doubted, and to them we must in a great 
measure attribute the prevalence of epidemics, still more decisively 
the curious phenomenon alluded to in the last chapter, the diversity 
in the character of the epidemic diseases of different years. 

CONSTITUTION AND HABIT OF BODY. 

4. The last which I shall mention, in an enumeration of the 
important circumstances which modify the symptoms of fever, is 
confined in its operation to the affected individual; — I mean consti- 
tution and habit of body. The extent of influence which peculiari- 
ties of constitution and habit of body exert over the symptoms and 
character of fever is, however, less than might naturally have been 
expected. The important fact indeed is, that under circumstances 
the most opposite, fever often shows the most striking uniformity — 
that the young and the old, the robust and the delicate, the active 
and the idle, the dissolute and those of regular lives, exhibit, when 
attacked by fever, the same series of symptoms. Still a certain 
degree of allowance must always be made for the constitution and 
habit of body of the individual affected; and it has been found that 
a number of minute circumstances referable to this head, tend in 
different ways to the modification of fever Of these the principal 
are, the period of life, the temperament of the body, the tone of 
the fibre, the kind of diet on which the individual had been pre- 
viously nourished, and the state of the mind. 

The period of infancy enjoys a very remarkable exemption from 
idiopathic continued fever, although abundantly susceptible of fever 
in other forms. *< Labour, temperance as they increase the tone of 



64 VARIETIES AND SYMPTOMS 

the system; intemperance;" the period of youth, the sanguine 
temperament, and a full diet of animal food, with a proportion of 
wine or distilled spirits, give a tendency to an inflammatory cha- 
racter in the fever. On the other hand, weakness of body and 
flaccidity of fibre, whether the effect of original formation, or of 
previous diseases, or of great exertion, or long watchings, or defi- 
cient nourishment, conduce to the low and typhoid form of fever; 
and it is therefore in individuals of this habit of body, that the purest 
cases of typhus are observed. The state of mind is universally 
found to have great influence over the susceptibility of the body to 
the reception of continued fever. The depressing passions, anxiety, 
fear, despair, dispose to the propagation and add to the malignity 
of fever; while hope and confidence serve,' in a manner no less 
remarkable, to ward oft' its attack, or to stem its violence. 

I have already attempted to explain, that though continued fever 
should be considered as a single genus, yet for the convenience of 
illustration and description, it is useful to make some broad dis- 
tinctions among its various forms. I pointed out a division into 
inflammator)^, common continued, and typhous fever, as one that 
was well adapted for an elementary view of the subject. The 
symptoms commonly presented by these different forms of fever 
may next come under our notice. 

SYMPTOMS OF INFLAMMATORY FEVER. 

1. Inflammatory fever (the Synocha of Dr. Cullen) is not often 
met with in its exquisite form in this country. It is that, however, 
which fever assumes in all hot climates where there is no pecu- 
liarities of soil to interfere with its developement. It is instanced 
in the summer fever of Sicily and the Mediterranean, as described 
by Dr. Irvine, Dr. Burnett,* and others. Its invasion, which is 
generally very sudden, is marked by excessive prostration of 
strength, with some shivering, soon succeeded by a violent heat of 
skin, pain of back, head-ache, giddiness, and general uneasiness. 
The head-ache is very acute, the eyes are suffused and cannot bear 
the light, the countenance flushed. The temporal and carotid 
arteries beat violently. There is often bleeding at the nose, with 
restlessness; and occasionally, but by no means constantly, delirium. 
The tongue becomes rapidly coated with a thick fur. Nausea, 
vomiting of bile, great thirst, and a costive state of bowels prevail. 
The pulse varies' from 100 to 120, strong, full, and regular, the 
blood huffy, the pulse sometimes is weak, small and depressed and 
rises on bleeding. The respirations are quick; the skin hot and 
excessively dry; the urine scanty and high coloured. Violence in 
the degree of symptoms, and rapidity of progress, are the prevailing 



-* Irvine's "Obseivations on Diseases chiel^y as they cccui- in Sicily." — Burnett's 
Account of the Fever of the Mediterranean fleet.'' 



OF CONTINUED FEVER. 65 

characters of inflammatory fever. If suflfcrcd to run its coiii-se, it 
may prove fatal in less than twenty-four hours. If proper measures 
are pursued, the disease will yield; hut unless they are speedily 
resorted to, lingering convalescence will be found to follow, attri- 
butable in all probability to some local mischief in the delicate 
structure of some organ, particularly the brain, occasioned by the 
violence of the first atack. 

The above symptoms g'ive a g-cncral outline of the inflammatory form of fever, in 
liot, and also in cold latitudes, where the system is plethoric and strong- and the 
weather diy and other circumstances arc favorable to a hig"hly tonic state of the 
system. Its character is disting-uished by its violence, its regularity in all its 
paroxysms, ending- by a full perspiration, and a perfect remission; its characters 
where it is attended with no danger, as to tlie pulse and the state of the skin, 
resembles much the excited state of the system on using- violent exercise; the skin 
being- warm but not excessively hot; the pulse full, strong and regular, without a 
great deg-ree of tension. If, however, as above stated, the pulse becomes hard and 
vibrating-, the skin dry, harsh, constricted, red, and pimgently hot, the disease may 
be considered to be violent and dangerous. In the West Indies this holds good, 
and it is also described as occurring in the northern latitudes of Eui'ope. There are 
some varieties however which deserve notice, and will g-ive a general idea of the 
manner in which fever is diversified; thus Dr. Jackson describes a variety of inflam- 
matory fever in Jamaica, not unfrequent in summer in the United States, in which 
the pulse was frequent, quick, hard and vibrating during the paroxysm; the heat 
intense; the secretions and internal functions considerably disordered, with a drj"- 
and strictured state of the skin; the remissions obscure, with a preternaturally hard 
and frequent pulse; sometimes this state of the system is attended with greater 
degrees of UTitability, with marks of violent excitement during the fits, with g-reat 
languor and depression of spirits in the remissions; the pulse at one time hard, 
irregular and quick, at another frequent and low, sinking under a small degree of 
pressure; the heat of the body not always g-reat, but pungent, and leaving a dis- 
ag-reeable impression on tlie hand, the secretions irregular; the countenance con- 
fused, clouded and overcast, eye sad, sometimes inflamed, the feelings unpleasant, 
with great imtabihty of temper, and a strictured state of the skin. These symptoms 
are sometimes g-eneral, sometimes partial and connected with a local affection. If 
the substance of the liver or lungs is affected, the fever does not run high; if the 
membranes enveloping them, it is excessively so.* In general, the causes which 
produce this fever are excessive cold or heat suddenly applied, when the system is 
greatly excited by exercise, spirituous liquors, violent passion, as anger, favoured 
by youth, a robust habit and a residence in a dry air, or by animal food: the causes 
which predispose and excite fever before mentioned also have their effect. C. 

SYNOCHUS OR COMMON CONTINUED FEVER. 

2. The common continued fever of this and of most other tem- 
perate climates (the Synochus of Cullen) is less sudden in its invasion, 
less rapid in its progress, and all its symptoms are less violent. The 
patient is generally under its influence several days before he is 
confined to bed. The pulse at first is frequent and strong, but by 
degrees it loses strength without diminishing in frequency. The 
duration of the disease is very various; but when once the symptoms 
of fever have subsided, the convalescence is usually rapid. 



* A Treatise on the Fevers of Jamaica, 1795. Philadelphia, p. 92-3. 
9 



VARIETIES AND SYMPTOMS 



TYPHUS OR NERVOUS FEVER. 



3. To the severest cases of continued fever which occur in tem- 
perate climates, which have their origin, as we shall presently ex- 
plain, for the most part, in contagion, and which run a course of not 
less than three weeks, presenting in their progress a different class 
of appearances from those which characterize inflammatory fever, 
physicians apply the name of typhus. The detail of symptoms 
which has been already given obviousl}^points out that in inflam- 
matory fever, a high degree of arterial excitement is present, and 
such are classed together therefore under the title of the symptoms 
of excitement. With them, although in a minor degree, typhus 
fever may begin; but ere long they are succeeded by a set of symp- 
toms which denote a great depression of nervous energy, and which 
are familiarly designated under the title of the typhoid symptoms, 
or the sym,pto7ns of collapse. 

The patient complains of a slight feeling- of indisposition, of chilliness, 
alternated with slight and sudden flushes of heat, listlessness, uneasiness of the 
head, sleeplessness, or if he sleeps, he groans, starts or is otherwise uneasy, and 
rises without being refreshed, dull aching pain in the head and limbs, with soreness 
of the flesh; pulse at first quicker than natural, sometimes so weak in very dan- 
gerous cases as to almost disappear on rising from bed, or using any exertion; 
depression, sighing and oppression in breathing, nausea, want of appetite, which 
increase for several days, the patient being well enough to be up, without at the 
same time having the power to attend to business. The disease is then fairly set 
in, increasing in the evening and declining towai'ds morning. The tremor observed 
on putting out the tongue, or raising the hand, is perhaps one of the most charac- 
teristic symptoms of this fever; it occurs, both when it follows the common continued 
or other more violent forms, or when the symptoms set in typhous from the first: 

As the fever advances, these symptoms become more intense, particularly the 
nausea, general pains and confusion of head, and despondency; the pulse varying 
in quickness, in strength and fulness, at different periods of the day: 

Sometimes the disease sets in more violently; there are great pains in the back 
and limbs, weariness and a burning pain in the stomach, vomiting, vertigo, dim- 
ness of sight, and numbness of the extremities.* In other cases the rigors from 
the first are strong; ptdse small, soft, and sometimes irregular, with excessive 
uneasiness, dejection of spirits, and confusion of head; the tongue trembles, the 
limbs shake; sometimes the patient falls down suddenly in a lifeless state. f C. 

Man}^ of the characters of typhoid fever arc unsusceptible of accu- 
rate description; and of these the most remarkable is the expression 
of countenance^ so uniform as to make all typhoid patients, in a 
great degree, resemble each other. It is a very peculiar expression 
of anxiety joined to a flushed appearance of the cheeks. It is 
seldom wanting, and constitutes, in fact, a striking characteristic of 
typhus. The pulse in this form of fever is very frequent, generally 
averaging from 1 20 to 1 30, small and weak. ' As the disease advances 
it becomes intermitting and irregular; these symptoms increase till 
the extremities become cold some liours before death, when it 
ceases at the wrist in the above weak states of the j)ulse. The 

• rhihp, vol. i. p. 171. t il^itl- 



OF CONTINUED FEVER. 67 

breathing is frequent, weak, interrupted with sighing and a dry 
cough; the voice is low, weak, shriller and harsher than natural.'* 
The tongue, at first 'white, and' very much coated, becomes in the 
progress of the disease brown, or almost black ; it is dry and parched ; 
occasionally, instead of being coated, it appears 'chopped and firm, 
or' smooth and pra^ternaturalJy. red. Black sordes collect around the 
teeth. ' There is a difficulty of svv^allowing from the dryness of the 
throat, sometimes from convulsion in its muscles. ' The evacuations 
from the bowels are exceedingly foetid, and often black, or mixed 
with blood. 'Diarrhoea attends almost always the last stage of typhus; 
the bowels are distended with wind, and the danger is in proportion 
to the violence of this symptom; Dr. Smith says he never lost a case 
in which the bowels were constipated during the whole of the dis- 
ease, nor has he ever known a fatal case unattended by diarrhoea.' 
As the disease advances they are passed involuntarily. The urine 
is in like manner foetid, turbid, and in small quantity, reddish, 
clouded, "or watery like whey." The skin is hot and dry. ^ At 
first there frequently appears no peculiarity, the heat even appears 
lower than natural, but afterwards the sensation of a sharpness and 
burning is communicated to the fingers; the patient is thirsty, 
without appetite, is often nauseated, and rejects a viscid, colourless, 
transparent fluid, without taste or smell, or consisting of bile almost 
entirely, especially in hot climates, 't From an early period of the 
disease delirium occurs, of a low muttering kind; and tremors, 
subsultus tendinum, with total want of sleep, and great uneasiness 
or restlessness, supervene. Sometimes however there is stupor. 
* Delirium generally appears in the progress of the disease, and 
coma towards the last; sometimes the delirium partakes of the cha- 
racter of mania, and after recovery there is often a total forgetfulness 
of every thing that has passed during the disease; the hearing is 
often impaired almost from the commencement; the sense of sight 
is not generally weakened till the last, excepting in a few instances 
w^hen it becomes false or distorted. % The eyes appear dull, heavy, 
languid, and towards the end of the disease they become watery; 
sometimes they are much more sensible to light.' Typhus is 
further characterized by extreme weakness of muscular fibre. The 
slightest exertion, such as rising in bed, aggravates all the symp- 
toms, or even brings on a fit of syncope. ' Hemorrhagies take 
place most frequently from the bowels, sometimes from the nose 
and more rarely from the kidneys; and in adult females from the 
womb; livid spots appear on the blistered surfaces, which become 
black and gangrenous. '§ The body emaciates rapidly. Eflfusions 
of blood underneath the skin take place, and appear in the form of 
livid spots or streaks, called petechise and vibices. ' They are 

* Philip, p. 176, vol. i. t Philip, p. 178-9, vol. i. 

t Smith on Typhus, p. 30. § Smith, p. 34. 



68 VARIETIES AND SYMPTOMS 

either red, brown, or blackish; the darker the colour the more 
ominous are they: they appear generally on the breast and back 
from the size of a pin's head to an inch or two in diameter. Some- 
times they appear in large blotches giving the skin a marbled 
appearance. When they appear early they are thought to portend 
great danger; they indicate and are sometimes accompanied by 
mortification in the toes, fingers, nose, cheeks, lips, &c.* Some- 
times the latter periods of the disease are attended with groaning 
and uneasiness, proceeding from excoriation, retention of urine, or 
mortification of parts laid upon; it is necessary to discover the 
cause, otherwise the patient often falls a victim, or it retards com- 
pletely his recovery.'! The duration of the disease varies from 
two to three, or even four weeks; when, unless some favourable 
change or crisis takes place, the countenance collapses, the features 
shrink, the eye loses its lustre, the pulse sinks; and hiccup, rattling 
in the throat, coldness of the extremities, and profuse clammy 
sweats, with a cadaverous odour of the body, indicate the approach 
of death. 

Such are the leading characters of typhous fever. When only 
the mildest of these symptoms are present, the disease is called 
typhus mitior. When the same symptoms occur, but in their 
highest state of intenslt}^, and when to them are added such as 
denote malignancy, the disorder then assumes the character, and 
with it the name of typhus gravior. 

OF FEVER COMPLICATED WITH LOCAL AFFECTION. 

From the detail of symptoms which has been now given, it is 
obvious that inflammatory and typhoid fever, how^ever they may 
difier in some points, yet agree in affording evidence of deranged 
function in every organ of the body, — the brain, the heart, the 
lungs, the stomach and bowels, the liver, the kidneys and the skin. 
Cases both of inflammatory and of typhus fever have been observed, 
which follow the progress I have now attempted to describe, impli- 
cating equally every organ and function. These are cases of simple 
fever, but they are comparatively rare. It is much more common 
to sec one or other of these organs particularly affected. What the 
circumstances arc which direct the violence of the febrile action 
upon one organ or structure in preference to another, does not 
always appear, but it can sometimes be satisfactorily explained. 

CAUSES OP SUCH COMPLICATION. 

Peculiar conformations of body, hereditary predispositions, or 
the weakening of parts by jirevious diseases, have a tlecided influ- 

* Philip, p. 183-4, vol. i. f Ibid. p. 186-7. 



OF CONTINUED FEVER. 69 

ence. A stout young man, with a short neck, and of a full habit 
of body, if attacked by fever, will be more likely, cseter is paribus, 
to have symptoms denoting determination to the head, than a tall 
thin young man, with a narraw chest, and subject to cough. The 
latter, during the progress of fever, may very probably have diffi- 
cult breathing, with pain of side, and purulent expectoration. Much 
may be attributed also to the influence of climate and season; heat 
favouring the disposition to abdominal, and cold to thoracic affec- 
tions. 

But it must be confessed there is something more than this 
required to account for the phenomenon. What the exact patho- 
logical principle is, upon which it depends, has not indeed been 
hitherto explained, although some attempts towards elucidating it 
have been made. It appears, from numerous observations, that 
various states of disease of the brain and its coverings, both acute 
and chronic, such as blows on the head, fractures of the cranium, 
lacerations of the dura mater, tumours and abscesses within the 
substance of the brain, are not unfrequentl)^ attended by disease of 
distant organs; such disease being attributable simply to a state of 
disordered circulation in the encephalon, and disturbance in the 
functions of the brain. To the same cause, whatever be its precise 
nature, we refer many of those local affections with which fever is 
so frequently complicated. 

OP THE ORGANS AND STRUCTURES AFFECTED IN THE COURSE OP 

THE FEVER. 

It is a point of some importance to determine what the organs 
and structures are, most liable to become affected in the course of 
fever, what is the nature of these local affections, and at what 
periods of the fever they chiefly occur. 

1. Of the organs liable to become more particularly implicated 
in fever, the most important is the brain. The symptoms by which 
we judge of this having taken place, are those which we shall here- 
after describe when treating of phrenitis and apoplexy. The second 
in point of importance is the mucous membrane of the stomach and 
bowels. The symptoms denoting a particular affection of this 
structure, are usually now called the gastric symptoms. They 
are, pain in the epigastrium, nausea, and vomiting, a sense of ful- 
ness in the bowels, diarrhoea or dysentery. The liver may next be 
mentioned as liable to suffer in the course of fever. It is not observ- 
ed to any great extent in this country, but it is very commonly 
met with in hot climates, and gives a character to the endemic 
fevers of those regions. 

The pleura and pcritonicum are occasionally attacked; but next 
to affections of the head, by far the most frequent of all the local 
complications with fever, is disease of the mucous membrane of 



70 VARIETIES AND SYMPTOMS 

the bronchia, appearing in the form of cough, difficult breathing, 
increased expectoration, and general diffused pain over the chest. * 

NATURE OF THE LOCAL AFFECTIONS. 

2. Much controversy has taken place regarding the nature of 
the affection, under which the different organs labour when attack- 
ed in the course of fever. Dr. Clutterbuck, who urged the import- 
ance of these local determinations in fever, believed that it was 
inflammation; and seeing how much more frequently the brain was 
affected, than any other part of the body, maintained that continued 
fever was essentially inflammation of the brain. Others have 
argued, that in a large proportion of cases, the vessels of the affect- 
ed part are in a state, not of inflammation, but of distention, or con- 
gestion. A distinction has even been attempted between inflam- 
Tnatory typhus, in which the seat of disease in the system of arte- 
rial vessels, and congestive typhus, in which the branches of the 
venous system are concerned. It has been supposed that this dis- 
tinction between the inflammatory action of arterial capillaries, and 
the congestion of blood in veins, explains the diversities of morbid 
appearances found after death, and may serve as a guide in direct- 
ing us to the proper methods of treatment. Now allowing the 
possibility of such a state of congestion in the venous system as this 
(which, however, is very problematical,) it still remains to be shown, 
that it may not, and does not run into the other. Until this is done, 
w^e cannot attach any great degree of pathological or practical im- 
portance to the distinction. The appearances on dissection in those 
who die of fever sufficiently point out, that danger is chiefly to be 
apprehended from the occurrence of inflammation; and that against 
such a state, the measures of the physician are to be directed, when 
he has evidence of local disease complicated with continued fever. 

MORBID APPEARANCES FROM CONTINUED FEVER. 

Morbid anatomy, it must be confessed, throws but little light on 
the pathology or nature of fever; but it points out its effects, and 
illustrates in particular those local affections which we have men- 
tioned as so often coupled with fever. The most common morbid 
appearance in cases of fever, is a gelatinous effiision upon the sur- 
face of the arachnoid membrane; abscesses in the brain, filled with 
pus or a serous fluid; inflammation of different parts of the brain. 
Serum is sometimes found in the ventricles; besides which, we 
perceive in many instances, a fulness of the vessels of the brain, as 



• Dr. Crampton, in an essay, entitled ** Medical Report, contiiining- a brief 
account of the late Epidemic in Dublin," has given (page 48) an estimate of the 
relative proportions in which different organs were there pressed in fever. Out of 
755 cases, 550 complained of the head, 129 of the chest, and 76 of the abdomen. 



OF CONTINUED FEVER. 71 

if they had been subjected to anatomical injection. Occasionally we 
meet with extravasations of blood, or the deposition of purulent 
matter. In the thorax we find marks of inflamed pleura. Pus is 
sometimes effused into the cavity of that membrane. In the abdo- 
men there are occasional evidences of peritonaeal inflammation; but 
the most usual appearance is that of ulceration, more or less exten- 
sive, of the mucous coat of the intestines. Inflammation in all its 
stages appears in the different organs of the body. 

PERIOD OF FEVER AT WHICH LOCAL DETERMINATIONS TAKE PLACE. 

3. The last topic to which I proposed to advert in this division 
of the subject, was the period of fever at which these local deter- 
minations are most usually observed to take place. In a few cases 
it is at the very onset of the disease; and this circumstance is im- 
portant, as leading to the distinction between the states of oppres- 
sion and collapse. The attack of fever is always attended by weak- 
ness; but if the blood be at that period particularly determined to 
the brain, a state of apparently extreme debility is brought on, 
which has often intimidated the practitioner, and prevented the 
adoption of those decisive measures which might then be safely 
had recourse to, and which alone could ens-ure a favourable termi- 
nation. In a large proportion of cases where great weakness attends 
the onset of the disease, the symptom is to be attributed to a load 
oppressing the brain, to a state of oppression, and not of weakness, 
exhaustion, or, as it is called collapse. Local congestions, however, 
take place in the progress of fever more frequently than at its com- 
mencement. They have even occurred when the febrile symptoms 
have subsided, and the patient been considered convalescent. To 
decide, whether the symptoms which then supervene are referable 
to a state of oppression or collapse, is one of the most difficult points 
in the practice of physic. It can be effected only by a close atten- 
tion to particular symptoms. The pulse is for the most part the 
safest guide; but the appearance of the countenance, the position of 
the body, and other minutiae which clinical observation can alone 
teach, assist materially in the decision of the question. 

PRINCIPLES OF PROGNOSIS. 

The judgment of the physician regarding the probable course, 
duration, and termination of any particular case, is founded, in a 
great measure, on the observation of symptoms. This, in medical 
language, is the prognosis; and the principles by which it is regu- 
lated apply to a certain extent, to all diseases. 

1. There is, in the first place, 2l general prognosis, founded on 
an extensive view of disease, which enables us to give an opinion 
regarding the probable course of particular cases, without any minute 
attention to symptoms. Thus, we can confidently predict, that a 



72 VARIETIES AND SYMPTOMS 

case of catarrh, or sore throat, will end favourably; that a case oi 
acute rheumatism will prove tedious; a case of croup, hazardous; 
of consumption, hopeless. In treating of diseases in detail, some 
allusion to general prognosis will always be made. 

2. There is a prognosis applicable only to individual cases, and 
this is to be regulated by an attention to a number of minute cir- 
cumstances, in detecting which, and estimating their relative im- 
portance, the skill of the physician is eminently displayed. This 
part of his duty can be but imperfectly taught in books. It is gene- 
rally said to be guided by the presence or absence of certain symp- 
toms^ w^hich are set down under the heads oi favourable and unfa- 
vourable symptoms. These have been collected together with great 
industry by various authors, but taken singly they are not of that 
consequence which might have been imagined. It is impossible, 
indeed, to lay down with strict accuracy the rules of prognosis. In 
actual practice, it is commonly determined by several considera- 
tions of a general nature; and of these, it will be found that one of 
the most important, is the period of the disease at which a particu- 
lar symptom occurs. To be able to draw legitimate conclusions, 
therefore, w^ith reference to prognosis, from the observation of such 
a symptom, it is necessary to be well acquainted w^ith the usual train 
in which the phenomena of the disease manifest themselves, and the 
causes upon which each depends. The age and habits of the patient; 
the circumstances in which he is placed; the period of time which 
has elapsed before medical treatment is resorted to, and the possi- 
bility of employing medicines effectually, have also a most import- 
ant influence over the course and probable termination of the disease. 
They must all, therefore, be taken into consideration in determining 
the prognosis; but they are obviously much too indefinite for parti- 
cular investigation. 

OF MALIGNANCY AND PUTRESCENCY. 

The symptoms which denote danger in continued fever are 
those, first, of excessive inflammatory excitement ;* secondly, of 
topical congestion; and, thirdly, of great depression, or irregular 
action of the nervous power. Among the latter are included 
those which the older writers were in the habit of designating 
as the symptoms of malignancy and putrcscency, state of body, 
the notion of which has been, in latter times, the frequent subject 

* To g-ive some instances, the red and turgid face; the throbbing, quick, full, tense 
or hardpulsei immoderate and unquenchable thirst; indifference to liquids with a 
dry tongue, and great heat internally; sleep without refreshment; urine pale and 
clear; a Avy^ fiery, pungently hot skin, and delirium dui'ing the intervals continu- 
ing in spite of the remedies; a frequent hurried breathing and deep sighing. On 
the contrary, the abatement of these symptoms; tlie pulse becoming softer and 
slower; the skin of a natural temperature, moist, cool, and soft; a smooth white 
tongue; countenance cheerful; return of appetite; the urine depositinga brickdust 
coloured sediment, are favourable; bleeding from the nose, diarrhoea, or abscesses, 
arc so likewise. C. 



OF CONTINUED FEVER. 73 

of dispute. That the powers of the livuig body, in checking the 
putrescent tendency of all the animal matter, should be diminished 
in certain states of disease, does not, however, appear to be an 
unreasonable supposition. The following may be enumerated as 
the chief symptoms which denote malignancy and the putrescent 
diathesis. A loose or very imperfect coagulation of the blood — 
foetor of the evacuations — a squalid appearance and excessive cold- 
ness of the skin, and a cadaverous odour of the body — haemorrhages 
from the mouth, nose, stomach, rectum, or urethra; the blood being 
of a very loose texture, and quickly putrefying — petechiae and 
vibices — a disposition to gangrene in the skin, wherever it has been 
accidentally wounded, or abraded, or exposed to long pressure — 
the speedy putrefaction of the body after death. It would be 
necessary to clear up many of the difficulties in which the doctrine 
of the coagulation of blood is involved, before we could arrive at 
a satisfactory explanation of these phenomena; but in the mean time 
there are sufficient grounds for believing, that malignancy and 
putrescency in acute diseases, depend principally upon the functions 
of the brain becoming early and deeply implicated. 

It niayfurther be stated that in common typhus, a dilated pupil, a g"Iassy, inflamed, 
or staring- eye; ichorous, involuntary or cadaverous, smelling" evacuations; hiccoug-h; 
cold, clammy, and partial sweats, with a small, weak, creeping-, and tremulous 
pulse; with anxiety, restlessness, and a g-reasy colour of the face, or a sad expres- 
sion; low muttering-, orhigh delirium; starting- of the tendons; quick speech; voice 
altered; constant watchfulness, with incoherence; stern sullenness, or unmanage- 
able fur}' of mind; picking- of the bed clothes; blindness; inability to put out the 
tong^ue; difficult deglutition; sliding- down in the bed; lying- on the back; drawing- 
up the knees; insensibility, with a disposition to uncover the breast; or frequent 
attempts to g-et out of bed, denote the approach of death. C. 

FAVOURABLE SY3IPT0:HS. 

A variety of symptoms are mentioned by writers on continued 
fever, as favourable; such as deafness; ^^the pulse rising; becoming 
slower, softer, and stronger, the breathing easier and calmer, with 
a natural tongue; eruptions about the mouth; tumors behind the 
ears, miliary eruptions," diarrhoea, sediments in the urine, the 
breaking out of a sweat, natural state of the skin, or excessively 
cold state of it, with a full pulse, or a great sweat with the same 
state of the pulse, the pulse rising after stimulants, with an abate- 
ment of the stupor, tremor, &c. and the formation of abscesses. 
Upon the latter, much stress has been laid. They have been consi- 
dered as critical discharges, that is to say, as serving to carry off 
noxious humours generated during the fever. This point of doc- 
trine we do not now insist upon; and upon the whole it may be 
remarked, that there is no single symptom occurring in the course 
of fever, which can be set down as decidedly favourable; but that 
the probability of recovery must always be estimated by the charac- 
ter of the symptoms, when viewed in connexion with each other. 
10 



74 VARIETIES AND SYMPTOMS 

AVERAGE MORTALITY. 

The general prognosis in continued fever is certainly favourable. 
Under proper management, a large proportion of cases recover. 
This is a point which has been made an object of inquiry by differ- 
ent writers; and a very curious coincidence has been traced in the 
extent of mortality occasioned by continued fever, under circum- 
stances considerably d^-ifferent* The average of deaths in the 
hospitals of this country appears to be in the ratio of about one to 
twelve, which is believed to be considerably below the ordinary 
scale of the mortality of fever, when it occurs in private habitations, 
even with access to medical assistance. It varies of course with the 
general character pf the epidemic, the period of the disease at which 
it is first submitted to medical treatment, and other circumstances 
of nearly equal importance, the influence of which has been already 
adverted to.t 

The following- remarks from Philips' treatise, will throw some lig-ht on the nature 
of the prognosis: 

The urine has always been examined with the view of determining the state of 
the fever: From the latest observations it is determined, that sediments are found 
even in the healthy state of that fluid, and that certain circumstances determine 
their appearance, in a greater degree about the termination of fevers. The deposit 
from the urine is either red,' consisting principally of the lithic, or as it is now 
called, the uric acid; or it appears in the form of a cream-coloured or furfuraceous 
deposit; now and then, however, assuming more or less of a pink colour. The 
first, or the red (uric acid) deposit, is most copious when the diet is acescent; 
when the state of the digestive powers is debilitated; when there is much acidity 
in the prim?e vise; or, when the perspiration is checked, and the acidity which 
should have passed by the skin is thrown r.pon the kidneys. During fever, when the 
perspiration is cliecked, and the kidneys are debilitated, so that the acid is thrown 
off by neither of these cmunctories, it accumulates in the system; and when by a 
change in the disease the functions of the kidneys return, a large deposit of this 
matter takes place, and in this manner becomes an evidence of the return of health. 

The cream-coloured or branny sediment, is the residt of an alkalescent diet, or 
of an unusually free perspiration, which passes off the acid by the skin. This 
sediment, like the one first mentioned, only proves a healthy disposition in the 
vessels of the skin to perspire, and thus throw off the acid which permits the depo- 
sit to be made in the urine. t 

The same effects are produced by sudorlfics; Philip says that he could at any 
time produce a deposit in the urine, by exciting a perspiration with Dovers* 
powder. He also observes that, as this is the invariable result of an increase of 
perspiration, there can be no doubt these appearances in the urine are not the causes 
but the consequence of recovery. § 

Sweating is the most general mode by which fevers terminate, particularly 
intermittents and remittents; and it is certain, that the best effects are produced by 
general and long continued sweats, if the patient, notwithstanding, retain his 
strength. Sometimes it continues for days and nights, and terminates in liealth;|| 
it is necessary, however, to keep up the strength, otherwise the patient would be 
exhausted. Regarding this evacuation as the consequence and not the cause of 

• Consult Bateman*s " Succinct Account of the Contagious Fever of tliis 
Country." London, 1818. Page 75. 

t See pages 59, 60, 61, 62, 63. t Philip, vol. i. p. 189—90. 

§ Ibid, p. 190. H Ibid, vol. i. 191. 



OF CONTINUED FEVER. 75 

recovery, its discharge is to be promoted only so far as is consistent vv ith the 
strength of the patient. I'he unnatural means used by heating medicines and warm 
clothing to keep up the perspiration, has destroyed many lives. It is only when 
sweating reheves the symptoms that it is to be encouraged, and that only by 
gentle and mild means. This symptom, however, is sometimes not critical; thus, 
in the yellow fever excessive sweats have been observed to be pernicious. In the 
sweating sickness, which appeared in England, it was a principal and a fatal symp- 
tom. The same observations apply to diarrhoea, hemorrhagy, as to the discharges 
of urine and sweat. When they are excessive and debilitating, they destroy life 
instead of relieving the disease, and it is only when the evacuation is attended with 
an evident abatement of the disease, that they are usefid. In ardent and inflamma- 
tory fevers, hemorrhagy is particularly useful, and often critical. This is true of 
the synocha of temperate latitudes, where a sufficient quantity of blood flows to 
cure the disease; in causus or yellow fever, however, bleeding from the nose has 
been considered as a mortal symptom; for it shows an extreme degree of inflam- 
mation of the brain, which the discharge is not sufficient to relieve. The physician 
can do much, when symptoms of hemorrhagy appear in any part, by drawing 
blood and assisting nature in her efforts. The symptoms which generally precede 
it, are pain, heat, and tension in the parts from which Ihe blood is to flow. In 
general the discharge takes place from the nose; an unusual redness of the eyes; 
an increased secretion of tears; a sense of weight in the temples, throbbing, dim- 
ness of sight, itching of the nose, and the pulsus dlcrotus, each stroke of which 
consists of one long, immediately after succeeded by a short beat, portend its 
appearance; those causes of fever which Increase the power of the system, or its 
plethora, are most likely to end in critical hemorrhagy; these are excessive eating, 
drinking spiritous liquors, or suppressed discharges.* 

A scabby eruption appearing about the lips, or behind the ears; an increased 
secretion of mucus from the throat, or of saliva, with aphthae; are often critical; 
the latter, when light-coloured and attended with a flow of saliva, are often 
favourable; when they are not accompanied with a flow of saliva, and are dark 
coloured, they are symptoms of danger.-j- The suppuration of the glands, particu- 
larly the parotid, are often favourable. The experience of authors dlfiers much upon 
the propriety of opening these swellings. Prlngle and Farquhar advise the open- 
ing of the parotid as soon as it showed a disposition to suppurate; Acrel, however, 
found the strength to sink soon after the abscess was opened. The balance of 
authority is on the side of laying the abscess freely open, as soon as it is discovered. 
The armpits, groin, and testicles are their most common seats, t 



Philip, p. 195, vol. i. t Ibid, p. 196. t Ibid, p. 198. 



( 76 ) 



CHAPTER III. 



CAUSES OF CONTINUED FEVER. 



Exciting causes of Continued Fever — Of Cold as the cause of 
disease in general — Of Fever in particular — Jilternations of 
atmospheric temperature — Of Contagion — First accounts of 
Contagion — General doctrines of Contagion — Of Fomites — 
Other supposed causes of Fever. 

EXCITING CAUSES OF CONTINUED FEVER. 

It was stated, in the first chapter (page 49,) that the exciting 
cause of continued fever admitted of a division into the two great 
classes of common and specific. The first of these, ^' such as cold, 
excesses in eating and drinking, sudden changes of weather," are, 
in a measure, obvious to our senses; and their operation is, to a 
certain degree intelligible. The second, as contagion, &:c. are more 
recondite in their nature, and their mode of operation is very obscure, 
if not altogether inscrutable. Another well-marked line of distinc- 
tion between them may be drawn from the circumstance of the first, 
or the common causes of fever, inducing this state of disease rapid- 
ly, while the latter require a certain, and generally a defined length 
of time, before their influence is apparent. Feverishness suddenly 
brought on by any of the more common kinds of irritation, is, for 
the most part, transient in its course, and has accordingly received 
from nosologists the name o^ Ephemera. 

OF COLD, AS THE CAUSE OF DISEASE IN GENERAL, &C. 

Any irritating causes are capable of engendering fever in the 
human body; but this they will more particularly do, when the 
frame is predisposed to fever, cither by peculiarity of tempera- 
ment and habit, or by the state of the mind and nervous system, 
or by certain conditions of the air. Those which are most fre- 
quently observed to operate as exciting causes of fever, are, exter- 
nal injuries, the presence of worms, difficult dentition, an over- 
. loaded stomach, the free use of wine or distilled spirits, excessive 



CAUSES OF CONTINUED FEVER. 77 

fatigue, insolation (or exposure to the direct rays of the sun), long 
watching, or long protracted pain. Of all the common causes of 
continued fever, however, the most frequent is cold; and as cold 
will hereafter be mentioned, as an occasional cause of several other 
diseases, besides fever, both acute and chronic, we shall direct our 
attention in a more particular manner to this branch of the subject. 

It becomes, in the first place, a matter of some importance to 
determine, in w^hat manner cold is to be considered as the cause of 
disease, and particularly of febrile disease. The simple diminution 
of temperature seems to give a predisposition to some forms of 
chronic disease, particularly scrofula, but its effect is never fever. 
We are constituted so as to bear extremes either of heat or cold for 
a long time, without suffering in our health. But though cold 
applied to the body under common circumstances does not create 
fever, the case is widely different when i: is applied suddenly, or 
partially, or irregularly, or when the body is overheated and per- 
spiring profusely, either from the nature of the climate, or from 
great exertion, or exposure to artificial heat. The importance of the 
function of perspiration, in regulating the uniformity of animal 
heat, and the actions of other organs, is well known to the physiolo- 
gist, and is illustrated by him in various ways. It seems probable 
that it is through the medium of this function that cold operates in 
the production of fever. It closes the pores, checks perspiration, 
and drives the blood in increased quantity upon the internal organs. 
When we look to the vast extent of the skin, and reflect on » the 
immense quantity of blood with which it is supplied, it is not diffi- 
cult to understand that this disturbance in the operations of the 
animal economy should be occasionally productive of bad effects, 
and experience shows that of these the most usual is fever. 

When once fever is excited, it may assume different appearances. 
In many cases the mischief falls upon some particular organ of the 
body, the tonsils, the lungs, the liver, the bowels, or the joints; 
and is directed upon them, sometimes without an}^ apparent cause, 
at other times in consequence of some cognizable circumstance, 
such, for instance, as weakness in the structure of the organ, or a 
liability brought on by previous disease. This is an important law 
of the animal economy, which serves to explain many points in 
pathology, and which, therefore, will be frequently referred to. 
There are few constitutions indeed which have not some one organ 
more disposed to disease than another. Original conformation, age, 
mode of life, habits, diet, climate, and season, and the disposition 
left by previous disorders, with many others, contribute to this, 
and it is one great source of the varieties of disease. According; to 
the- constitution then of the individual, will in many cases be the 
result of exposure to cold. When the general disturbance of all the 
functions of the body takes place, cold is said to generate idiopathic 
fever. 



78 CAUSES OF CONTINUED FEVER. 

ALTERNATION OP ATMOSPHERIC TEMPERATURE. 

Closely allied to cold in the mode of its operation is sudden 
alternation of atmospheric temperature. This has been observed 
in all countries to be a fruitful source of febrile diseases, and of 
none more than continued fever. Nowhere is it better exemplified 
than in this country, so remarkable for the unsteadiness of its cli- 
mate, which in the course of four-and-twenty hours not unfrequently 
exhibits the succession of the four seasons. These sudden changes 
of atmospheric temperature are particularly favourable to the pro- 
duction of fever, and are, per se, capable of exciting it. In this way 
we account for the greaser comparative frequency of continued 
fevers, haemoptysis, and inflammatory affections of various kinds, 
in spring and autumn, than at any Other period of the year. 

A diminished temperature as an ag-ent in producing^ disease, is regulated by 
several circumstances. When it descends below 55° or 60°, it will produce disease, 
according to certain circuicstances, more or less readily; these regard, first, the 
power of the cause itself; second, the power of the constitution, which resists the 
morbific agent. 

1, The power of the cold itself may be increased, by being applied suddenly, 
as in a sudden cold wind, or plunging suddenly into cold water,- by being applied 
to a part of the body when it is kept generally warm; by being applied by mois- 
ture united with a current of air; by sudden and great alternations of temperature.* 

2. The power of the constitution which resists the morbific agent, may be 
diminished by any cause, which increases the weakness of the system; thus, the 
patient may be weak naturally; or, he may be debilitated by excesses; as, by bleed- 
ing, purges, low diet, intemperance, fatigue, or gluttony; the body being in a per- 
spiration, and deprived of its accustomed coverings. The truth of these causes is 
demonstrated from the fact that their opposites,-f- a strong constitution, exercise, 
wholesome food, pure air, a contented mind, give a vigour to the co.nstitution which 
enables it to resist all attacks. Cold acting in this mode, produces fevers of an 
inflammatory character; as, rheumatism and pleurisy, &c. palsy of the muscles, 
most probably from the inflammation of the nerves, which go to them; local 
inflammation, as, in chilblains and gangrene.i: It also produces apoplexy, and it 
is, in general, from this cause, that persons, who die from intense cold go oflT. C. 

OF CONTAGION. 

Continued fever, however, has another and a very important 
exciting cause, which frequently operates where neither cold nor 
alternations of atmospheric temperature can be suspected, as where 
fevers attack persons shut up in close rooms with others labouring 
under the disease. When fever appears under such circumstances, 
it is said to have its origin in contagion. A number of the most 
important doctrines of the science of pathology are closely associ- 
ated with the subject of contagion. From the earliest periods at 
which it became an object of inquiry, this has been acknowledged; 
but the investigation is obscure nnd difficult, and lias proved a 
source of endless controversy. Many of the disputed points in 

» Cullcn's First I/mes. | Ibid. \ Ibid. 



CAUSES or CONTINUED FEVER. 79 

medicine are interesting only to the man of science; but the doc- 
trines of contagion are of general interest, because involving prac- 
tical considerations of the highest importance. Without attempting 
to clear up all the difficulties in the way of the inquiry, I shall be 
satisfied with a brief enumeration of its leading positions, and of the 
principal points in dispute. 

FIBST ACCOUNTS OF CONTAGION. 

1. Attempts have been made to throw discredit upon the doctrine 
of contagion as the caiise of fever, by showing that it was for a long 
time either unknown to, or disregarded by physicians. It is certainly 
a curious fact, that for the first dawnings of information concerning 
it, we are indebted, not to Hippocrates or Galen, but to ancient 
poets and historians. Thucidydes, in his account of the epidemic 
fever or plague that raged in Athens during the Peloponnesian war, 
shows that he undeistood contagion in the sense in which we now 
use the term; — noxbus matter from one morbid body producing a 
similar disease in atother. In Plutarch's Life of Pericles we read, 
that whilst that co.nmander was laying siege to the city of Epidau- 
rus, a distemper prevailed in his army, which not only carried off 
his own men, but all that had intercourse with them. Livy, in 
the account of a camp fever which affected the armies of the Romans 
and CarthaginiarB at the siege of Syracuse, distinctly states that it 
was propagated py contagion. Virgil and Lucretius employ the 
term contagion :o express the manner in which a disease of sheep 
spread among tic flock. 

Medical writers were for the most part, very inattentive to con- 
tagion until thetime of Sydenham, in whose work (sect. ii. chap. 
2.) a distinct reference to contagion may be met with. Boerhaave 
and the followers of his school were very incredulous on the subject 
of contagion. Their ideas about it too were imperfect and confused, 
from the circumstance of their blending the notion of contagion 
with that of marsh miasmata. Dr. Huxham, Dr. Lind, and Sir 
John Pringle, are the great original writers on contagion, particu- 
larly on that of continued fever. Since their time the subject has 
undergone the most rigid examination, and as we have said has 
given rise to the most discordant opinions. 

GENERAL DOCTRINES OF CONTAGION. 

2. Much confusion has been introduced into the subject of conta- 
gion, by the employment of the term infection, and by the difierent 
acceptations in which contagion and infection have been taken.* 



* See " Evidence taken before a Committee of the House of Commons, ap- 
pointed to inquii'e into the validity of the Doctrine of Contagion in Plague." — 
1819. 



80 CAUSES OF CONTINUED FEVER. 

This has been increased by the want of a proper distinction between 
common contagion and specific contagion. Diseases w^hich cannot 
be produced in any other way than by contagion, are said to have 
their origin in specific contagion. Of this kind are small-pox, 
cow-pox, measles, the plague, hydrophobia, and syphilis. Diseases 
which, occasionally produced by contagion, are yet sometimes 
owing to the operation of other causes, are said to arise from com- 
mon contagion. Of this kind are catarrh, cfnanche, parotidaea, 
erysipelas, ophthalmia, typhus, and scarlatina. The laws of common 
and specific contagion are in many respects similar, but they have 
also their points of difference. To illustrate these, and to deter- 
mine the peculiarities of each individual ccntagion, w^ill be an 
important object in future parts of the work. 

3. In the last paragraph I have assumed as an established prin- 
ciple what has been, and w4iat is still made lie subject of keen 
dispute; viz. that typhus fever does originate Irom contagion, and 
that it is of the kind which we have called common, in opposition 
to specific contagion. Both these points ha\e been called into 
question. By a few, and happily a very few, it l.as been contended, 
that the notion of a contagious origin of typhus ^ever is altogether 
unwarranted; but the views of these anti-coniagionists are so 
completely at variance w^ith the generally rece ved opinions of 
medical men, and so irreconcileable with facts obnous to all man- 
kind, that any formal refutation of them is unnecessary. On the 
other hand, there have been, and there continue t) be, physicians 
who believe in the exclusive origin of t)^phus from contagion, who 
maintain that no disease can propagate itself by (ontagion which 
had not its own origin in contagion; in other words w^ho deny that 
common continued fever, under any, the most adverse circum- 
stances, can ever spread by contagion. This opini)n involves the 
difficult, but for the most part idle question, how contagious fevers 
ever originated; but setting this aside, it may fairl} be argued that 
it is neither borne out by observation nor by reasoi ing. There is 
nothing improbable in the supposition, that what originated in cold 
may be afterwards propagated by contagion. It violates no estab- 
lished la\v of the animal oeconomy. Experience on the other hand 
appears to favour it; and it may therefore be laid down as an 
important practical principle, that fever which originated in the 
first instance from common causes, may under certain circumstances, 
either of local situation or constitution of body, spread by conta- 
gion.* What those particular circumstances are, which thus concur 
to favour the developement of febrile contagion, may be anticipated 
from remarks already ofibred. The principal of them are, crowded 
and ill-ventilated apartments, want of cleanliness and comfort, and 



* This view of the question is now g-enerally known by the name of the doctrine 
of contingent contagion, and it has received the support of the most able cotcm- 
porary pathologists. 



CAUSES OF CONTINUED FEVER. SI 

previous weakness of tlie allccled individual, vvhetlier owing to 
excessive fatigue, or an unwholesome or scanty diet. 

Whatever debilitates the mind or body is to be avoided; as th 3 weakness of 
either leads to the developement of fever when tlie contagion has been received. 
Sudden fear, horror, joy, or the excitement of any strong passion, particularly 
contributes to it. Intoxication, fatitjue, nig-ht watching", gluttony, intense study, 
exposure to the sun, so as to fatigue, are all dangerous; and if debility is produced, 
it is necessary to obviate it immediately, otherwise the fever will appear. 

Chewing opium and tobacco to tliosc who arc accustomed to them are proper, 
as they will keep up the strength to its usual height; but to those who are not 
accustomed to them, they must be considered as sources of debility; as to the use 
of tobacco as a preventive of the access of the poison to the stomach, it is an idle 
precaution, since the lungs must be considered as the great avenue through which 
the miasmata enter the system. 

Mercury and issues have all been advised; and with regard to the former cer- 
tainly with some reason, since it cures the fever, when it is already formed, though 
in some few instances, fever may continue during a salivation; these, however, are 
rare. Issues might be used at jthe same time with a salivation. Purges have also 
a good effect, but more particularly in preventing bilious and the yellow fever. 
"With regard to tiie use of camphor hung round the neck, of mercury put into a 
quill, and other contrivances of this kind, they are to be considered as fancies, and 
of no practical use.* 

The general use of such diet, exercise and modes of life, as are best consistent 
with strength, is the great mean by which prevention is to be effected; thus the 
use of digestible food, as mutton, beef, and fowls broiled, regular exercise in the 
open air for several hours, at the same time avoiding tlie sun and the morning or 
evening air, more particularly in warm seasons and latitudes, an easy, equable mind, 
freedom from care, and all the depressing passions; to avoid exposure to the con- 
tagion, or if that is impossible, to be greatly exposed to it, as habit weakens its 
effect, will all deserve attention : The sleep should be regular, as the want of it 
frequently brings the contagion into operation. 

The separation of the sick from the well, in houses appropriated for that purpose, 
is one of the most effectual modes of arresting contagion, and after it has taken 
place, proper nursing to conduct them through it; thus, to attend a person in the 
yellow fever, an African or West India negro will be less likely to be endangered 
by it, or be interrupted with improper fears in their duties, and a person who has 
lived in a filthy suburb of a city will be most proper to attend typhous patients. 
Persons from a high cold situation or latitude are not proper nurses for the diseases 
of summer, or in low latitudes. The acclimated, those who are not afraid of the 
disease, the temperate, and those of a sound constitution, are the best persons 
for niu'ses; it is particularly necessary that these cautions should be attended to, as 
frequent death among the attendants may spread the alarm and render it difficult 
to procure the necessary comforts for the sick. 

The use of the Peruvian bark and other bitters has a fine effect in preventing 
fevers, particularly of the remittent and intermitting kind; and as it has great power 
in keeping up the strength, it is in every respect a valuable aid in fevers of all 
kinds. Its use was tested in Hungary during one of the campaigns of Austria in 
that country. The retinue of a certain count was completely protected from the 
ague by the bark, whilst the army generally without this precaution was obliged 
to remove on account of the prevalence of the fever. C. 

4. Many of the controverted points in the doctrine of contagion 
hinge upon this question; but there is another fundamental one, of 
almost equal importance. Sydenham long ago urged it with much 
force of argument, and a due attention to his observations might 
have prevented much of the controversy which has lately taken 



* I'hilip, p. 231. 
11 



82 CAUSES OF CONTINUED FEVER. 

place on the subject of the plague and yellow fever: — I mean thai 
particular constitution of the atmosphere, which disposes to, or 
which checks, the diffusion of all febrile contagions, whether 
common or specific. It is well ascertained, that a contagious dis- 
ease, even of the most malignant kind, which may have gained 
footing in a populous city or district, does not necessarily attack 
every one within its sphere, or go on progressively to the destruc- 
tion of all the inhabitants. Several circumstances contribute to 
this; first, peculiarities of constitution, which secure certain indivi- 
duals completely from the influence of the contagion; and, secondly, 
the immunity from future attacks, which in several instances of 
febrile contagious disease is afforded by once undergoing it. To 
this last law of contagion, w^e shall have occasion to refer more 
particularly, when the eruptive fevers come under consideration; 
but for the present it may be stated, that it applies, although with 
some exceptions, to typhus fever. These two circumstances assist 
in explaining the fact just mentioned, but they are not fully ade- 
quate to the effect. A certain constitution of the air, therefore, 
sometimes favouring, but sometimes checking the diffusion of con- 
tagion, must be admitted as a third general principle upon which it 
depends. 

Some physicians have pretended to find fault with this multipli- 
cation of causes for explaining a single phenomenon, and have 
argued that a peculiar, or, as Sydenham says, an epidemic consti- 
tution of the air, is of itself capable of explaining what others refer 
to the combined operation of it, and of the principle of contagion. 
As well might they argue, that the tree could be reared without a 
seed, because a peculiar condition of the soil is required for its 
reception and growth. Several of the most important facts in the 
histories of great epidemics, particularly the plague, will hereafter 
be illustrated by a reference to the foregoing fundamental doctrines 
in the laws of contagion. 

5. Much speculation has taken place among medical authors, 
regarding the mode in which contagion produces its effects on the 
animal oeconomy. It has been observed of a number of diseases 
notoriously arising from contagion, that they exhibit, even from an 
early period, symptoms of great depression of nervous energy, or 
of collapse. This is exemplified in the case of plague, typhus, 
cynanche maligna, influenza, erysipelas; and it has hence been 
imagined, that there is in the nature of contagion something which 
is directly sedative or depressing to the nervous energy. A more 
extended view of disease would show the fallacy of this as a general 
principle. Measles and ophthalmia, which yet exhibit all the marks 
of genuine inflammatory excitem,ent, are diseases, as obviously 
arising from contagion, as plague or typhus. The operation of 
contagion may possibly be upon the brain and nerves, but its precise 
effect upon them is altogether inscrutable. Still, while I offer a 
caution against assuming as a principle of pathology any thing 



CAUSES OF CONTINUED FEVER. 83 

sedative in the nature of contagion, I am not insensible to the 
importance of the fact, that cases of disease arising from common 
contagion, above all continued fevers, are more likely to be of the 
low or typhoid kind, than such as are attributable to cold, or other 
causes independent of contagion. 

6. Of the intimate nature of the contagious particles which arise 
from morbid bodies, and which produce a like disease in others, 
we know nothing; but there are a few particulars known or con- 
jectured regarding the manner in which their influence is exerted 
on the animal oeconom}^, which it will be proper to notice. 

7. Great attention has been paid by Dr. Haygarth and others, to 
determine the distance to which the noxious effluvia extend, and 
at which they operate in exciting disease. There is reason to believe 
that this varies in different cases, and that the plague, typhus, and 
small-pox, have, in this respect, each their several laws. The 
subject, however, does not appear to have been yet investigated 
with sufficient accuracy, to enable us to lay down any established 
points of doctrine with regard to it. It is not exactly known, how 
far the sphere of contagious influence is affected by ventilation. In 
the case of continued fever, we are warranted in saying, that a 
free circulation of a pure and cool air renders the contagious par- 
ticles comparatively inert, and that concentration is nearly, if not 
altogether, indispensable to the activity of contagion. * 

It may be conveyed by the wind. This was proved by the fact that some 
prisoners in London, after living in close, badly ventilated apartments, communi- 
cated the disease to those members of the court, upon whom the wind, from a 
window, blew in a direction from the prisoners, whilst others who were not exposed 
to the impregnated blast escaped.f 

All those circumstances favour the effect of contagion, which favour its increase 
and accumulation; as a stagnant air. In Vienna there was a calm for three months; 
during that time, the plague raged; on the rising of a wind, the disease was miti- 
gated.t 

A warm and moist air, as it favours putrefaction also favours the spread of conta- 
gion; thus the plague spreads more readily in damp and foggy, than in dry and clear 
weather. The debility produced by dampness may also contribute. The stools 
produce most readily the disease; the breath next; and next the perspiration. § 

The contagious matter is very indestructible. Mead states that the smoke of the 
burning clotlies of the sick has produced infection. C. 

Some physicians have extended their views farther, and have 
maintained that there are certain chemical substances which have 
the power of decomposing contagious effluvia, or, at least, of render*- 
ing them, in some way or other, innoxious. Of these, the principal 
are acid vapours, particularly those of the nitric ^^ muriatic," acetic 
acids, and chlorine. Fumigation therefore has been recommended 
as a powerful means of counteracting contagion. The theory upon 
which it has been introduced is exceedingly doubtful, and the prac- 



* .On this subject consult "Facts and Observations regarding Infection," by 
Sir G. Blane. *' Transactions of a Society for the Improvement of Medical arid 
Chirurgical Knowledge.'*- — Vol. III. page 425. 

t Phihp, vol. i. p. 213. ^ Ibid. p. 214. § Ibid. p. 216. 



84 CAUSES OF CONTINUED FEVER. 

tice far from being generally applicable, acid vapours of all kinds 
being more or less injurious to breathing. If fumigation is adopted 
as a substitute for thorough ventilation, it may prove injurious; if 
only superadded, it is perhaps superfluous; but on a point of such 
practical importance it is right to speak with much caution. 

The nitric acid may be made by adding- some nitre to heated sulphuric acid in 
cups placed at the distance of 20 or 30 feet from each other; the muriatic acid is 
prepared by heating- common salt moistened with sulphmic acid; the oxymuriatic 
or chlorine is made in the following" manner: 

Mix an ounce of a mixture made of equal parts of powdered manganese and 
common salt, add a tea-spoonful of water and half a tea-spoonful of sulphuric acid 
from time to time, and thus a constant supply of the g-as will be furnished. It is 
particularly necessary not to inliale the fumes of this air in their concentrated 
state, as they produce consumption. 

Sulphur burnt on coals is also used; it however affects the respiration, and there- 
fore is improper. The acetic acid is used principally in the form of the aromatic 
, vineg-ar; it is too limited in its operation; it is, besides, decomposed by throwing' it 
upon coals, and in that mode, thoug-h commonly used, its virtues are entirely lost. 

The uselessness of odoriferous fumes was shown by Guyton Morveau in the 
church at Dijon, which was hig-hly infected by the effluvia of dead bodies; it con- 
cealed but did not alter the properties of the effluvium. Tar, Lind reg-ards in the 
same lig-ht.* Morveau used the muriatic acid vapour in 1773 with good effect to 
disinfect the church, by filling- it with its vapours. Guyton Morveau recommends 
the following- mode of preparing- the oxymuriatic acid: Pour about two and a half 
ounces of the nitrio-muriatic acid upon a drachm of the oxide of manganese in a 
four ounce bottle; the vapor will be immediately produced :f but it must be observed 
that it will be disengaged in great quantities, and may be dangerous if inspired. 
All metallic substances must be covered to prevent its effects. Lind says that 
clothes and other articles to which the matters of contagion may adhere, may be 
purified by baking them in an oven, or exposing them to the heat of a confined 
fire, which he says no infection can resist. C. 

8. Attempts have been made to ascertain the exact period at 
which contagion begins to exert its influence; and it has been satis- 
factorily shown, that in this respect each particular contagion 
acknowledges a diflerent law. The latent period of typhus (that 
is to say, the time which elapses bet^v<Jen exposure to the contagion, 
and the first symptom of fever) is generally from ten days to a 
month, but it has been known to extend to six weeks, or even two 
months. Physicians have also attempted to determine at what 
particular period of a disease its contagion is the most active, and 
when the body ceases altogether to aflbrd contagious matter. This 
point it would be of much importance to ascertain, as it would 
indicate when a patient might safely be permitted to mix in society; 
but unfortunately there do not appear to be sufllcient data to enable 
us to decide the question with any degree of accuracy. 



OF FOMITES. 

9. The last subject of inquiry which the general doctrine of 
contagion oilers, is the attachment of contagious particles to certain 



Bateman, a Succinct Account, p. lOJ-4. Lond. 1818. \ Ibid. p. 165-6-7. 



CAUSES OF CONTINUED FEVER. 85 

bodies, thence called Fomites, where they lurk, often for a very 
long period of time, and subsequently renew the disease with all its 
former, or even with increased virulence. It is the most curious 
fact in the history of contagion, and one established upon the most 
unquestionable evidence. The principle too appears to be of more 
general application than any other which the doctrine of contagion 
involves. The plague and typhus, small-pox and scarlet fever, 
ophthalmia and porrigo, afford the most familiar illustrations of it; 
but it is doubtful if there is any species of contagious disease, which 
may not be communicated through the medium 6i fomites. They 
may be either hard or soft bodies. The walls and wainscoting of 
the room, beds and bed-furniture, the furniture of the room, and the 
clothes of the patient, are those against which we are chiefly to be 
on our guard. It is well ascertained, that the clothes of an indi- 
vidual, who is himself unsusceptible of the disease, may become the 
fomites of its contagion. In this manner typhus, small-pox, and 
plague, are not unfrequently disseminated. 

From the continued accumulation of the matter of contag-ion in linen, cloth, or 
walls, &c. it appears, that it is often more dangerous than the body itself; upon 
this subject most authors agree. Lind supports the idea, and Smith states that the 
linen of the sick is more dangerous than even the dissection of the dead body. 
Wool and wood are the most apt to retain it.* 

The poison of contagion may from habit not affect those who are constantly 
exposed to it; whilst their clothes may carry it and give it to others. This hap- 
pens sometimes in courts, to which prisoners are brought from filthy prisons. 

The intensity of the poison varies under different circumstances; it is much 
greater, when produced in the latter periods of the disease, when petechise, vibices, 
and cold cadaverous sweats occur. 

Its effects also vary according to circumstances; thus a person who has the 
small-pox or the measles, will have a fever resembling that of tliose diseases 
respectively, but there will be no eruption; he may also have the typhous fever, 
and it may die away after it has continued for several days. He may have the 
infection in his system, and if he is exposed to no debilitating cause it will 
not appear; whereas, those who have been exposed to a debilitating cause, as 
excessive drinking, fatigue, will be taken with it immediately after the debility is 
produced. Those, who are recovering from a contagious disease, excepting those 
which arise from specific contagion, ai-e more subject to a return on being exposed 
to the poison, which originally produced it.f C 

Such are the most important topics which the general doctrine of 
contagion embraces. They are brought forward in this place, 
because contagion, as a cause of continued fevers, demanded par- 
ticular notice. It remains however for me to observe, that besides 
those exciting causes of continued fever which have now been 
mentioned, there are some others to which this form of disease has 
been attributed, which, at least, deserve to be enumerated. Of these 
the first is a vitiated state of the air, in consequence of the accumu- 
lation of persons in a confined space. 

^ Thus, some of the persons confined in tlie black hole of Calcutta 
were taken with this fever. Shutting down the hatchway produces 



Phil. p. 216. . t Ibid. p. 218.19. 



86 CAUSES OF CONTINUED FEVER. 

it in ships; the poor in London take it from confinement in their 
dwellings during a scarcit)'^ of fuel, and when removed to the house 
of recovery soon improve from the purity of the air. ' 

The second is the putrefaction of animal and vegetable matters. 

' Any putrefying matters may have the same eifect: to this it has 
been objected that glue manufactories have diffused the most noisome 
stenches for miles, from the putrefaction of the materials, without 
affecting the health of the neighbourhood; but this is no objection, as 
in these instances the miasmata may not have been sufficiently 
concentrated; and as it appears that there have been diseases pro- 
duced by the putrefaction of animals, as of the dead after a battle, of 
a whale in Holland, &c. there can be no doubt that animal putrefac- 
tion is sufficient to produce it. 

' It would appear, that as there are certain parts of the system 
which nature has intended to be eliminated from it by the 
excretions, that these are particularly noxious, w^hen confined 
about it and re-admitted into it; this is also the case with animals; 
thus sheep confined in great numbers in a ship generated a fever 
among them, which did not extend either to the crew, or to some 
hogs which were near them; after some time the hogs took sick 
with a fever, which also was entirely confined to them, proving 
evidently the power of the causes, which arise in every species, and 
that their operation is confined to the species itself. These animal 
substances which are excreted from the body of every animal, it is 
probable have more power; but if putrefying matter of any kind be 
of sufficient intensity, it will produce this fever, modified in its 
symptoms by the particular poison which produces it, but resembling 
this fever in its more general characters. Indeed typhus may follow 
any fever which is protracted, and which debilitates the patient 
sufficiently. It may therefore be considered as a state of the S3^stem 
when under fever, in which its actions are highly debilitated, and 
which may proceed from all causes which produce fever and debility. 
If it continue long enough, and the situation be sufficiently confined, 
the result is contagion in the same manner, (but with more power,) 
as any other putrefying matter will do.' 

The third is a state of famine or scarcity The prevalence of 
fever at particular periods has been often attributed to one or other 
of these sources, and many occurrences in history favour the opinion. 
That they powerfully contribute to the diffusion of fever when 
once generated, cannot be questioned; but they have all been so 
frequently observed to exist without fever ensuing, that their power 
of exciting, per se, this state of disease, must still be considered 
among the doubtful points in medical science. 

The rules of prevention may be gathered, from what has been said on the sub- 
ject of the causes of typhus; removal of the sick from the sources of contagion; 
personal and domestic cleanliness; a residence in the upper stories of houses; 
ventilation; this may be effected during- an epidemic by closing the doors and 
windows of the house, and kindling fires in several chimnies; the air will then 
descend througli the others, as it cannot gain admission through the doors and 



CAUSES OF CONTINUED FEVER. 87 

windows. Hospitals are sometimes ventilated in tliis manner; a passage for the 
air is opened through the upper parts of the windows, whilst fires are kindled 
towards the ends of the wards. The imperfection of this plan, however, has been 
proved, as it is stated, that birds die when placed on the floor of the ward, when 
they were in perfect health while placed in the upper parts of it. It is, therefore, 
necessary to ventilate them both from apertures near the ceiling- and the floor. 

The means wliich have been generally recommended for purifying the air, have 
but little power; thus the burning of large fires during the prevalence of an epi- 
demic, has been found to be useless; excepting, perhaps, when itl destroys dwell- 
ings which have been for a long time the receptacles of domestic filth; results 
confirmed by repeated experience. 

Camphor, juniper, frequently applied to the nose, tobacco chewed, steams of 
vinegar diffused through the sick chamber, arc all of doubtful efficacy. The acid 
vapours above mentioned are most to be depended upon; particularly the chlorine.* 

"With regard to purifying houses, hospitals, and ships, the mixture which pro- 
duces the chlorine is to be placed in different parts of them, and the windows, 
chimneys, hatches, are to be shut, and thus the gas may be made to peneti-ate 
completely every part of them. 

Furniture and clothes may be purified by exposure to the air, and washing. 
Clothes should be well aired before they are washed, to prevent infection on 
washing them; previous to which, they should also be soaked in soap and water, 
as the steam arising from infected clothes, is said to be dangerous. 

Smoking clothes, ships and houses, which are infected, completely frees them 
from any infection. It has been customary since the infancy of medicine to use 
sulphur; arsenic has also been proposed for the same purpose; smoke answers 
very well; but the chlorine and other acids have superseded every thing else.f 

Pitch, tar, rosin, cascarilla, camphor, juniper, pine tops and shavings, have also 
been used.t Wood and woollen articles should be dispensed with as much as 
possible. Iron bedsteads, and brick floors are most proper for hospitals. C. 

• Philip, p. 220-6. f Ibid. p. 228. t Ibid. p. 228-9, 



( S8 ) 



CHAPTER IV. 



TREATMENT OF CONTINUED FEVER 



Necessity of Treatment in Fever — Indications of Cure — The 
antiphlogistic Regimen — Possibility of cutting short a Fever 
— Remarks on the different Means resorted to in the treatment 
of continued Fever — The Mstr action of Blood — Cold */iffu- 
sion — Emetics — Saline and Jlntimonial Medicines — Purga- 
tives — Cordials — Bark — Opia tes — Bliste^^s. 

NECESSITY OF TREATMENT IN FEVER. 

It is well remarked by Dr. Cullen, though in every fever which 
runs its full course, there is an effort of nature of a salutary tendency, 
and though from hence it might be inferred that the cure of fevers 
should be left to the operations of nature, or that our art should be 
directed only to support and regulate them, it yet requires but a 
moderate share of observation to understand that these are very 
precarious, and often wholly insufficient to overcome the disease. 
Permanent derangement of the function or structure of an organ is 
sometimes occasioned before such operations are set up, and a 
reliance upon them therefore often leads to negligent and inert 
practice. The necessity of treatment in fever is now indeed gene- 
rally acknowledged. Occasionally, the natural tendency of fever 
to terminate favourably may be kept in view with great advantage; 
as, for instance, in the latter stages of simple fever, where measures 
of depletion are unnecessary, and wine and cordials would be 
doubtful remedies. In a large proportion of cases, however, the 
operations of nature may be superseded by the well-directed exer- 
tions of art. To point out what these arc, to what extent they may 
be carried, and how they must be varied to meet the varying forms 
in which fever presents itself, is my object in the present chapter. 
It is to be regretted, that the nature of the subject is such, as to 
render it impossible to lay down any specific directions for the 
guidance of the student, as we may hereafter be able to do, when 
explaining the treatment proper in pneumonia, colic, or jaundice. 
All that can now be done is to notice the principle means that are 



TREATMENT OF CONTINUED FEVER. 89 

resorted to in the cure of fever, and to add such observations as may 
throw light on the objects for w^hich they are had recourse to, and 
point out the necessary cautions in their administration. In no 
disease is so much left to the discretion of the practitioner, as in 
continued fever. 



INDICATIONS OF CURE. 

The general objects to be kept in view in the treatment of any 
disease are called, in medical language, the indications of cure. In 
the case of fever, they have, for the most part, been drawn from 
the hypothetical views of authors regarding the nature and proxi- 
mate cause of fever; but such indications of cure are little calculated 
to direct us in the choice and application of remedies. The view 
which has been here taken of the varieties of continued fever, and 
of the circumstances which modify its symptoms, suggest the fol- 
lowing as the simplest indications of cure in fever. 

1st. To moderate the violence of arterial excitement. 
2d. To obviate local inflammations and congestions. 
3d. To support the powers of the system. 
4th. To relieve urgent symptoms. 

THE ANTIPHLOGISTIC REGIMEN. 

An important step towards the attainment of all these objects is 
a strict attention to the Antiphlogistic Regimen, under which 
term physicians include a great variety of details proper to be 
observed, not only in continued fevers, but in all febrile affections 
whatever. This regimen is of itself sufficient to cure a number of 
the slighter kinds of febrile disease, such as catarrh and sore throat. 
It consists in avoiding or moderating those irritations, which in one 
degree or another are almost constantly applied to the body. Dr. 
Cullen has divided them into three classes: — impressions made upon 
our senses; — the exercise of the body and mind; — the taking in of 
aliments. In all fevers, therefore, care is to be taken to guard against 
external heat, and such impressions upon the eye and ear, as would 
prove painful to the patient, and aggravate the symptoms of his 
disease. The popular prejudice against the admission of fresh air, 
the use of cold washing, and the frequent changes of linen and bed- 
clothes, in cases of fever, is now gradually giving way; but for a 
great length of time it exerted a most pernicious influence over the 
treatment of fever. All exertions of body and mind are to be for- 
bidden. The horizontal or a gently raised posture, " on a moderately 
hard bed," is to be enforced. The presence of aliment proving 
always a stimulus to the system, abstinence is to be recommended, 
particularly from animal food in the shape of broths and jellies, 
12 



90 TREATMENT OF CONTINUED FEVER. 

which are too often had recourse to in tlie early stages of fever 
They load the stomach, increase the disposition to nausea and 
vomiting, accelerate the pulse, augment the heat of the skin, and 
occasion head-ach, flatus, tormina, and many other unpleasant 
symptoms. The utmost cleanliness is to be observed in the patient's 
person, and in every thing around him. His thirst is to be allayed 
l3y liglit, subacid, and cool drink, " by acid fruits, or simple cold 
water; by a solution of tamarinds, of cream of tartar; by apples 
sliced into water; or lemonade. In highly inflammatory cases, 
exposure to a current of air gradually abates or gives relief to the 
fever. When the stomach rejects cold drinks, the comfort of the 
patient may be consulted by taking it by table spoonsful, by hold- 
ing a piece of ice in the mouth, or by eating slices of oranges or 
lemons cooled by ice." 

The use of cold drinks are most proper after the hot stage is completely form- 
ed, and are not to be used after the perspiration has broken out; the temperature 
must be steadily and clearly above what is natural; g-iven in this manner, they 
promote perspiration and sleep, and diminish the heat and frequency of the pulse, 
if given during- the perspiration, they sometimes produce a sudden chill on the 
skin and at the stomach, with debility and irregular breathing, reducing the heat 
of the system suddenly and considerably; a bladder filled with water to the pit of 
the stomach of the temperature of 110° to 115° of Fahrenheit, small and frequent 
doses of ether, with latidanum, then suddenly relieve.* At the very commence- 
ment of the sweat, cold drinks are sometimes Ijeneficial. The bed clothes and 
linen when changed, when the patient is pcrsi)iring, should be warmed and dried 
near a fire; the visits of friends should be prevented, or the presence of many 
attendants, as they tend to render tlie air impure. With regard to the temperature 
of tlie room it should be cool, and of this, the patient's feelings, when he is sensible, 
should be the criterion; about 62° is considered as a temperature, which is not 
stimulating, if that of tlie patient is above 98°, nor depressing if it be below, and 
most likely to produce tlie sensation of comfort; but as every case varies, it is 
necessary to ascertain by the feelings of the patient exactly the temperature which 
is most agreeable to him; but it must be one wliicli is agreeably cool, and if the 
fever be veiy inflannnator}', so reduced as to make it cold: 

This latter injunction is very important, particularly as it is observed in hot sum- 
mers and tropical countries, that in ])roportion to the heat is the tatality of the 
fever, and that removal to a high and cold situation, in the West Indies, often cures 
it. It is, therefore, of the greatest consequence to have our houses so constructed 
as to secure a constant, steady and reduced temperature, by double wii\dows, thick 
walls, and cold air from an icehouse properly situated, so that pipes could be sup- 
plied from 62°, and lower as tlie case rec^uired. This is particuhu-ly necessary in 
the case of the aged and of children, who are so easily debilitated by excessive 
heat. 

In Philadelphia after a month of excessive heat, medicine in the cases of children 
becomes entirely useless; the regulation of tlie temperature is, therefore, of the 
greatest im])ortance, and will be considered hereafter. Fanning and exj)osurc of 
the naked body to a current of air, will reduce tlie temperature very much. The 
practice of Sydenham of administering mild fujuids; as milk and water, given 
with the view of lowering the excitcTuent, has of late been entirely iieglected; I 
liavc no experience on the subject. So powerful is it in abating excitement, that 
Sydenham gave a caution against Its frecjuent use, as it had a tendency to bring it 
too low. C. 



Currie. 



TREATMENT OF CONTINUED FEVER. 91 

POSSIBILITV OF CUTTING SHORT A FEVER. 

Before proceeding to n dctnil of tlie other means wliicli are resort- 
ed to in the treatment of continued fever, it is necessary to inquii-e 
how far it is possible, by a vigorous emj)loynient of measures in the 
early stages of a fever, to cut it sliort. The question has been much 
agitated, and there are. many autliors who contend that it can fre- 
quently be effected. It may fairly ])c admitted, that there are mild 
attacks of fever, particularly such as occur in yovmg persons, where 
a prompt evacuation appears to have the effect of interrupting that 
chain of morbid actions, which ends in the full developement of 
fever; but it may reasonably be doubted, whether any of the severer 
cases of continued fever (those, for instance, either arising from 
contagion or from common catises, which extend to. fourteen or 
twenty-one days,) could have been cut short hy any exertion of art. 
Were it possible to do so in a few cases, it should yet be home in 
mind, that active treatment in the majority of cases of continued 
fever, even though early resorted to, is chiefly serviceable, not in 
shortening the course, but in moderating the violence of the disease. 

The cases, however, on record arc so numerous, in which the use of certain 
remedies have succeeded in cutting" short tlie fever, that it is always adviseable to 
try them; thus, in inflammatory fever, a fall bleeding", the cold efi'usion promptly 
and vig-orously administered, have had the eifect of completely checking" the 
disease; and in typhus, when the patient is g"oing- about in a listless state, with 
creeping" chills, lassitude, Sec. an emetic is g-iven with the same good result, and as 
soon as it has operated, ten g"rains of carbonate of ammon'.a, ^vith draughts of vine- 
gar whey, as advised by Pringle, to excite a perspiration, or the emetic may be 
omitted, and the sudorific given alone, always observing the precaution of giving 
clean linen, free ablution, with warm vinegar and water, to purify the skin, ami 
assist in the perspiration; and the removal of all sources of filth, which might per- 
petuate the disease; Dr. Rush mentions that Ur. Beardsly, of Connecticut, saved 
during a dysentery, many soldiers froin infection, by having their beds removed 
from the wall of the room, and when convenient, placed in the middle of it,* a fact 

C. 

OF BLOOD LETTING. 

Of the different means of fulfilling the indications of cure formerly 
laid down, the most powerful is the abstraction of blood. Every 
part of the treatment of fever has heen the suliject of controversy, 
but the employment of blood-letting is that, wiiich of all others has 
been the most keenly disputed. As it is however of the greatest 
importance to have clear ideas regarding it, I shall make an attempt 
to estimate the utility of blood-letting in fever, and to point out the 
circumstances under which it may 1)e proper to employ it.t 

There cannot exist a doubt as to the necessity of blood-letting in 
the genuine inflammatory fever, the endemic of hot climates. The 



* Rush's Pringle, p. 269—70. 

f Nowhere have I seen this subject more clearly stated than in the writings of 
BagUvi, chap. vi. section 3. 



92 TREATMENT OF CONTINUED FEVER. 

violence of that disease, the rapidity of its progress, and the high 
degree of arterial excitement which characterize it, call for the 
adoption of a system of measures, at once powerful and immediate 
in their effects. On the first attack, therefore, blood is to be taken 
from the arm to the extent of twenty or thirty ounces, and in a full 
stream. This it is frequently necessary to repeat in the course of a 
few hours; the extent of the evacuation being always regulated by 
the violence of the symptoms, particularly by the degree of head- 
ache, '' tensity," and the fulness of the pulse. These must be 
diminished without delay; and though other means are not to be 
neglected, it is upon venesection that our chief reliance is to be 
placed. Some have urged opening the temporal artery in preference 
to bleeding at the arm, but without sufficient reason; and here it may 
once for all be said, that opening the temporal artery is not an ope- 
ration to be recommended, except under particular circumstances. 
It often fails, even when practised by skilful hands. The requisite 
quantity of blood cannot always be obtained speedily, or estimated 
accurately. There is, lastly, often considerable difficulty in secur- 
ing the artery, nor does it appear that there is any peculiar benefit 
resulting from the operation to counterbalance those obvious disad- 
vantages. 

With regard to the employment of blood-letting- in fever, Its use is indicated by 
so many urgent and strong" reasons, as the principal, most easy, and certain mode 
of cure, that a slight review of them here will be advisable, more particularly as it 
bears in its curative effects upon so many of the phenomena of the human system. 
The reader will recognise in the following remarks, an abstract of the results of 
the labours and enquiries of the late Dr. Rush, (detailed in his admirable essay 
upon this subject,) to whom the public are too much indebted, to require any 
eulogy in this place. 

ADVANTAGES OF BLOOD-LETTING. 

Blood-letting has many advantages in the cure of fever; it arrests it suddenly; it 
lessens pain; renders the pulse more natural, when too slow, too full, or too fre- 
quent. It checks nausea and vomiting, as in the malignant bilious fever, also 
diarrhoea in the measles; and tenesmus after dysentery, when all its other symptoms 
have ceased; it opens more easily the bowels when costive after taking physic 
during fever; it promotes salivation by mercury, and sweat, when the ordinary 
diaphoretics are given; it removes and lessens pain in every part of the body, also 
the burning heat of the skin; it checks and moderates profuse sweats; cures 
intolerance of light, coma; it induces sleep, and prevents eflusions of serum and 
blood, cough, consumption, jaundice, abscess in the liver and dropsy; the results 
of autumnal fever; also the termination in gangrene of the malignant fever. 

It prepares the way for the action of tonics; as, the bark, and by rendering fevers, 
wliich were remittent, of an intermittent type, it, readily, with the aid of these 
medicines cures them. It prevents relapses, for by being practised in time, in 
inflammatory diseases, it cuts them short, before a sufficient degree of debility is 
produced to produce a return on the application of slight exciting causes. 

OBJECTIONS TO BLOOD-LETTING ANSWERED. 

The prevalence of hot weather has been given as an objection to the use of the 
lancet. The natives of hot climates do not require it to the same extent, but 
without it, in proper quantities, they cannot be so speedily cured. Great apparent 



TREATMENT OF CONTINUED FEVER. 93 

weakness also so far from being an objection to its use in highly inflammatory 
cases and robust habits, is the strongest proof of its necessity. Neither is it 
improper in infancy and childhood; in those stages of life, the blood-vessels are 
more active. In old age, from free living and indolence inducing a fuller state of 
the blood-vessels, it also becomes necessary. Dr. Rush's opinion in this respect is 
supported by that of Botallus, who considers that blood-letting is more necessary 
in aged, than in youthful subjects. Hoffman also supports the same idea; it is also 
more required during menstruation and pregnancy, as the blood-vessels are pecu- 
liarly excitable and feverish in these states of the system. Fainting and coldness 
of the extremities do not always contra-indicate it. Petechiae and sweats did not 
prevent Sydenham from using it with success. The long duration of a fever often 
shows a chronic inflammatory state of disease, which, therefore, becomes an addi- 
tional reason for bleeding. The same is true of inflammations, as pleurisy; bleeding 
should be practised, where there is pain, or a tense and oppressed pulse. 

The circumstance, that patients are worse after the second bleeding, should not 
prevent us from using the lancet again; thus Dr. Rush mentions, increase of heat, 
chills, delirium, hemorrhages, convulsions, nausea, vomiting, faintness, coma, great 
weakness, pain, a tense after a soft pulse, and its reduction in force and frequency, 
as proofs of the system rising to a state of vigour from one of depression, by the 
action of this remedy, and therefore as demanding its repetition. Chills following 
J)leeding, occur in those fevers, in which, from the high excitement of the system, 
no chill appeared; bleeding reduces it, and a less malignant state is the conse- 
quence. Dr. Rush even states some cases to show that in malignant fever cold 
hands and feet and a ghastly countenance, the result of the fourth bleeding, in one 
case, were removed by a fifth; during the flowing of the blood the pulse rose; the 
patient was bled three times afterwards, at the end of three, ten, and seventeen 
hours; it fell and rose again by these successive bleedings, in all of which were lost 
thirty ounces of sizy blood, and so gi-eat was the vigour acquired by the pulse, that 
it required seven more bleedings to subdue it.* 

Cordial medicines given in the depressed pulse often take away life. They are 
given under the absurd idea of raising the system, which is impossible by that 
means; for when given during inflammatory fever, as has been proved in all the 
varieties of inflammations, dysentery, he. they induce apoplexy, epilepsy, coma, 
&c. and convert what was before a mild, into a malignant and deadly disease. 

Dr. Rush obviates the objections to its inducing the nervous fever by stating, 
that when employed to a degree sufficient to prevent the gangrenous state of 
fever, a lower grade than the nervous, it may induce the nervous fever, but if 
employed in a degree proportioned to the disease, the fever instead of being ren- 
dered chronic or nervous, would be eradicated entirely by it. 

As a general remedy, the circumstance that it induces debility is rather in its 
favour, for it is by that quality alone that it operates; without it it would not be a 
remedy at all. With regard to its inducing a habit requiring its frequent repetition, 
this is an objection which applies to the healthy state of the blood-vessels; then 
by abstracting blood frequently it may induce plethora; but in disease it cannot; 
for properly employed it may reduce the blood-vessels to their healthy standard, 
but can do no harm. Sometimes it is used to prevent a greater evil, as in case of 
strangulated hernia. 

If it produces excessive debility, effusions of serum, in the chest, bowels, limbs 
and brain, it is because it is not drawn in suflficient quantity, or at the proper time. 
In general, its tendency to produce dropsy is feared only in mahgnant fever; in 
pleurisy, it is not dreaded, though malignant fever is a disease in which the action 
of the blood-vessels has been subjected to a cause far more prostrating than in 
pleurisy, and of course this state of fever requires a more powerful degree of a 
debilitating remedy to counteract the operation of this more powerful cause. 



* In this case it must be recollected that tlie symptoms occurred early in the 
disease. Dr. Rush mentions that in fevers which terminate in five days, it will be 
imprudent, even with a tense pulse to bleed after the third day. 



94 TREATMENT OF CONTINUED FEVER, 



CASES IN WHICH BLEEDING SHOULD NOT BE USED. 

Here, before going any farther, we must recall the reader to those cases, in which 
blood-letting- is thought to be pernicious, and to other cautions, which direct its 
proper administration. 

1. It should not be used in those states of fever, in which there are great con- 
gestions of blood in the viscera owing to the weakened state of the arteries, as it 
may debilitate their action and increase the congestions; they must be relieved by 
frictions and stimulating applications to the extremities, gentle stimuli taken by 
the mouth, and cordial injections into the bowels; as soon as the system is a little 
excited by tliese remedies, blood may be drawn in small quantities, by cups or 
leeches, applied to the seats of congestion, and when the blood-vessels are sufii- 
ciently excited, it may be taken in proper quantities from the arm, in order^to 
lessen the action. 

It is seldom proper beyond the third day of a malignant fever, if it has not been 
used on the days previous to it; even tlie tension of the pulse is not always a suffi- 
cient warrant to take blood, in a fever which runs its course in five days; the lancet 
is useless in such cases. Purges, blisters, and a salivation are the remedies here. 

It should be used with great caution in the close of the paroxysms of intermit- 
tents; it then weakens too muclu 

It sliould not be used in the weak and frequent pulse resembling that of typhus; 
cordials, gentle vomits and purges arc then the remedies; also in the diseases of 
habitual drunkards; also after the suppurative process has begun in local inflam- 
mation; also after copious expectoration has taken place; this discharge serves the 
purpose of local depletion; if, however, there is great pain in coug'hing and a tense 
pulse, bleeding may be used. It may be omitted wliere there is time to wait with 
safety for the slower operation of purging and abstinence. The use of this remedy 
is not always followed with benefit, even when the pulse is tense; Pringle and 
others record instances of it; and sometimes when the ptdse is tense, bleeding will 
not subdue it, as in hemorrhages: extreme pain is the only circumstance which 
can justify bleeding in these cases: however, these are irregularities which occur 
but seldom. 



BLOOD-LETTING COMPARED WITH OTHER REMEDIES. 

It is said that vomits, purges, sweats, salivation and blisters are a more safe mode 
of depletion; to this it may be replied: 1. that vomits are more uncertain in their 
operation; 2. they are unsafe, as in pregnancy; in apoplectic constitutions; in rup- 
tures; and in cases wlierc spitting of blood is threatened; they also induce cramj), 
bleeding, and inflammation in tlie stomacli; 3. they arc also incontrollable, operating- 
less or more than was intended; 4. they are also often ineffectual in mild, and 
always so in fevers of great morbid action. 

Purgatives, besides being uncertain and uncontrollable, often kill from the dan- 
gerous debility they produce. Sweating, besides being lial)le to these objections, 
is often by no means safe, as, when produced by antimonial medicines of that class. 
Howard and Goldsmith, it is said, were killed by James's powder: even mercury, 
which has subdued the malignant fever, lockjaw, and some other violent diseases, 
by abstracthig two or three pounds of fluid from the system daily, compared with 
bleeding, is less manageable, because it cannot sometimes be brought to operate, 
thougli pounds of it are taken; it is not so quick in its operation as to be vahuible 
in dangerous cases; it is a disagreeable and painful remedy, and cannot when the 
discharge is excited, be regulated, as blood-letting can. 

Blisters are too feeble a remedy; the quantity of evacuation they produce, is too 
small to produce any great effect upon a fever, and in general they are inappli- 
cable, from tlic irritation they produce to high grades of inflammatory action. Low 
diet is too slow and weak in its operation to subdue an inflammatory fever: 

IJlood-letting has many advant:iges over other modes of depletion; it abstracts 
the principal stimulus from the direct seat of mischief in a fever; viz. the blood- 
vessels: and thus relieves, hke a grain of sand taken from the eye, in inflammation 



TREATMENT OF CONTINUED FEVER. 95 

of that organ. It is quick, manageable, is not troublesome, gives little distui-buncc 
to tlic system, and is less ofTensivc than some other modes of depletion; it is 
attended with no immediate danger to life, is less dcbihtating when used in its 
proper degree, is followed by a more rapid convalescence than when vomits or 
purges arc used; besides, it does not preclude the use of other remedies. 

THE STATES OF THE PULSE WHICH INDICATE BLEEDING. 

The following states of the pulse Dr. Hush states to indicate bleeding; 1. a full, 
frequent, and vigorous pulse, without tension, as it occurs in gout and apoplexy; 
2. a tense; 3. a jerking; 4. a quick and tense; 5. a slow and tense pulse; 6. an 
uncommonly frequent pulse, without much tension, beating from 120 to 170 beats 
in a minute, occurring in tlie malignant states of fever; 7. a soft pulse, without 
much frequency and fulness; 8. an intermitting pulse; 9, a depressed pulse; 10. an 
imperceptible pulse, indicating increased action in the brain.* 

THE STATES OF THE PULSE WHICH FORBID BLEEDING. 

The slow, uncommonly frequent, intemnitting and imperceptible states of the 
pulse, which require bleeding may be distinguished, says Dr. Hush, from an 
exhausted or debilitated state of the system, and that forbid bleeding, by the 
following marks : 

1. They occur in the beginning of a fever; 2. they occur in the paroxysms of a 
fever, which have remissions and exacerbations; 3. they sometimes occur after 
blood-letting, from causes mentioned before; 4. they sometimes occur and continue 
during inflammations of the stomach and bowels; 5, they occur in relapses after 
the crisis of a fever. Dr. Rush considers that force and irregularity are the quaU- 
ties of the pulse which principally demand our attention, and that frequency 
should not be much considered, since this quality is much under the influence of 
the passions, motion, and diet, and of course our judgment upon it liable to be 
disturbed by frequent and accidental causes. 

Sometimes the pulse gives no indication of the force of disease; a red colour of 
the clieeks, drops of blood coming from the nose; no diminution of the heat of the 
body after bleccling, and the existence of an inflammatory constitution of the atmo- 
sphere; a recent attack; the part attacked vital; great pain; diflficult respiration; a 
watery, lively, or suffused eye, are signs that the pulse may be disregarded, in the 
opinion of Dr. Rush.f 

OTHER CIRCUMSTANCES WHICH REGULATE THE USE OF THE LANCET. 

The prevailing epidemic, if inflammatory or otherwise, must assist us in deter- 
mining the necessity of bleeding; an hereditary disposition to inflammation demands 
bleeding; the season of the year and the state of the weather influences its neces- 
sity; thus, in dry or in cold weather, bleeding is more necessary than in moist or in 



* Hunter states that in inflammation of the brain the pulse varies more than in 
inflammations of any other part, and perhaps we are led to judge of inflammations 
there, more from other symptoms than the pulse. — Rush's Works, vol. iv. p. 331. 

f It may, however, here be observed, with the greatest deference to the me- 
mory of Dr. Rush, and it is a fact well worthy of note, that the redness of the face as 
if it were painted witk red lead, and the watery eye, resembling its appearance 
after crying, when the tears are begiiming to disappear, are almost certain signs 
of bile in the stomach, and requhe emetics repeated frequently, or purges to 
relieve it; the anomalous symptoms, produced by the ])resencc of this fluid, are so 
numerous and various, that they personate almost all diseases, and every variety of 
pain and convulsion. When the red lead-coloured face, and the lacrymose eye 
are present, emetics and pui-gatives have a most beneficial eflTect. C. 



96 TREATMENT OF CONTINUED FEVER. 

long continued hot weather; corpulent people do not bear bleeding so well as 
those who are lean and spare; nor citizens so well as country people. If the patient 
be accustomed to be bled, more should be taken; if large in person, also the quan- 
tity should be larger. 

Dissolved blood, blood of a scarlet colour, without separation of its parts, denote 
the use of the lancet; the former, however, only in the first stage of fever, as after- 
wards the loss of blood is perfectly useless. Blood with serum resembling the 
washings of flesh, serum of a red or green colour, the bufly blood, all hkewise 
indicate it. These signs (from circumstances mentioned by our learned author 
immediately afterwards) of diseased blood, are not to be taken as unequivocal 
evidences of its necessity, since it is altered very much by the size of the orifice, 
by the manner in wdiich it flows into it, slow or fast; the dissolved blood with an 
oppressed pulse, and the buffy blood, are the best signs; the former, only, as was 
before observed, is proper in the first stages, or in robust habits. It should be 
copiously and rapidly drawn, when taken in inflammatory diseases, particularly 
where the organs in a state of inflammation are important to life. Much less may be 
taken, if two blood-vessels are opened than one; if the blood be taken in a standing 
posture than if lying down. Sydenham relates the history of a number of cases of 
the plague successfully treated by bleeding in a standing posture nearly to fainting, 
and before any eruptions appeared: The yellow fever has been cured by the same 
means; also accidental, sudden, and copious hemorrhages often cure common 
inflammatory fever. Sometimes it is necessary to bleed a robust person in a supine 
posture, in order to take away as much blood as will overcome tlie disease; other- 
wise, it will be necessary to repeat the operation; if, on the contrary, the person 
should be debilitated, a sitting posture will be more advisable, to produce the 
requisite debility the sooner, or they may be bled to a few ounces in a lying pos- 
ture and suddenly raised to a sitting one, and thus the requisite debility will be 
induced. 

The removal of pain, faintness, the pulse becoming steady and feeble, and the 
blood of a thin consistence or not coagulating, are signs of a sufficient bleeding. 

The signs of the inflammatory diathesis may here be presented to the reader, as 
occurring in the highest grade of that type of fever, and indicating this evacuation; 
the full, tense, hard and bounding pulse, the face and eyes red, wltli a violent 
head-ach, high delirium, hurried breathing, swelled epigastrium, tongue white and 
dry, skin hot, with costlveness, and great uneasiness: bleeding tlien continued, as 
before observed, till fainting, in the highest cases will be proper. In malignant 
fevers, Dr. Rush says, that he has always observed the cure to be most complete, 
when the patient is pale in the face, and feels faint after bleeding; the remaining 
diseased action of the system time will wear away; in bleeding, however, in malig- 
nant cases, and where the pulse is depressed. Dr. Rush takes but three or four 
ounces at a time; and when the pulse rises he draws more, repeating it three or 
four times a day; the blood-vessels thus recover their tone; In all inflammatory 
cases, the nature of which is not exactly known, it Is best to begin with moderate 
bleedings, increasing it with the violence of the symptoms; fixing- no limit but the 
urgency of the case to the quantity of blood taken away: 56 and even 90 ounces 
have been drawn with the happiest effects; it is, however, only in the first stages 
of disease, that it is at all proper in such large quantities; as syncope, when induced 
in the last days of a disease, often produces death. 

Blood-letting, like all the other remedial measures of our art, has its dose, and it 
must be prescribed according to the case: three or four ounces lost often divert 
the action from the organs more important to life; and though the case is incurable, 
bleeding often eases pain, prevents convulsions, composes the mind, protracts the 
use of reason, induces sleep, and thus smooths the passage out of life. 

Blood should be taken from an artery, because, according to Dr. Butler, it is 
less likely to produce fainting, which in pregnancy almost always produces abor- 
tion; and more relief is obtained from a small quantity of blood taken from an 
artery than from a vein. Bleeding from the arm is more convenient, attended with 
less danger of wounding a tendon, than in the foot, and as in the latter case the 
foot is put into warm water, it is easier to ascertain the quantity which is taken 
from the arm. 

Local bleeding is proper where there is local inflammation, as from a contusion. 



TREATMENT OF CONTINUED FEVEK. 97 

orother injury, when the general fever has arisen from the affection of a part; when 
the local affection is evidently the result of the general fever, then general bleed- 
ing Dr. Rush thinks is preferable. 

Bleeding may be used at all times, the above signs and cases excepted, when 
indicated by the pulse and other circumstances, in continual fevers; and also in 
the paroxysms of such fevers as intermit. So necessary did Dr. Rush consider 
bleeding in the latter, that a student used to sit up with his patients, and when- 
ever the fever came on, he abstracted a few ounces of blood; when the fit went 
off", to avoid debility he gave the patient four or five drops of laudanum, which 
was followed by refreshing sleep. 

Common continued and typhus fever do not necessarily require 
the adoption of blood-letting. A large proportion of cases, especi- 
ally of the latter, would be hurt by it; and in many, to say the 
least, it is uncalled for. But, on the other hand, there are some, 
and those among the most formidable which fall under our obser- 
vation, which as imperiously require it. 

The object for which blood-letting is instituted in the common 
continued fevers of this country, and in genuine typhus, are vari- 
ous. Some recommend it very early in the disease, in the hope of 
cutting it short at once. This is a fortunate result of the practice 
occasionally witnessed; but it is one which can seldom be antici- 
pated. The legitimate object of blood-letting in these diseases, is 
the checking those dispositions to inflammatory action which are 
so often met with in severe cases, which sometimes come on insi- 
diously, and at other times suddenly, and are productive in either 
way of serious mischief to the affected organ. This applies with 
peculiar force to those conditions of the brain which are supposed 
to depend on congestion or i-z^^-fifcz^/e inflammation; for the delicacy 
of its structure exposes it readily to injury; and injury of the brain, 
even of the slightest kind, is always to be dreaded. It is frequently 
observed, that a judicious abstraction of blood in the early stages 
of fever not only diminishes the head-ache, the great sensibility to 
light and sound, the delirium, the cough, the pain and fulness of 
the abdomen, but it apparently shortens the course of the disease, 
and more obviously still, the period of convalescence.* 



* The evidences of the acute state of inflammation are general arterial turges- 
cence, sharp and fixed pains in the head, chest, or abdomen, anxious and oppress- 
ed breathing; a jerky, rapid pulse, with some hardness, and tensity, dryness of 
the tongue, blood-shot eye, hot and dry skin, cupped and bufty blood: 

The sub-acute is evidenced by httle or no pain, a frequent and less resisting 
pulse, at the same time some evidence of weakness, the tongue inchningto brown, 
with a greater degree of general anxiety and oppression.! These states of acute 
and sub-acute inflammation occur more frequently in tlie towns and cities of 
Britain, where a large mass of the poor live principally on porter, and take less 
solid food tlian they do in the United States; their systems are there more inflam- 
matory, and sooner sink into the low typhous state; the use of venesection, there- 
fore, both in these forms, and in the congestive state, in which the veins are in a 
state of plethoric turgescence, recommended so strongly by Armstrong, does not 
apply with the same force in this country, where our diet is more solid and nour- 
ishing. The re-action is here not so violent, and when it becomes typhous it is 
t Armstrong on Tvphus,p. 3d. 

13 



98 TREATMENT OF CONTINUED FEVER. 

It is at the onset of the fever, that is to say, betAveeii the first 
and fourth day, when the good effects of blood-letting are more 

best treated in the manner laid down by the old writers: that is, by n^ore sparing" 
venesection, taken early and only on the first or second day of the febrile state : 

The symptoms above described as acute and sub-acute, indicate a state properly 
typhoid; the use of depletion by moderate venesection, once or twice to 8 or 10 
ounces, or to 3 or 4 often repeated, are in the first days of acute symptoms proper, 
at the same time bleeding- locally from the seat of inflammation; the action, how- 
ever, soon subsides; g-eneral venesection will then be dang"erous; local bleeding" from 
the seat of the pain, with blisters and purg-es, will be sufficient. AVhere there is 
great g-eneral debility with local fulness in parts, towards the end of the inflam- 
matory stag-e, local bleeding-, g-iving wine at the same time, to support the strength, 
is sometimes necessary; the local and g-eneral indications are thus completely 
fulfilled: A blister to the part will confirm the effect: 

Occasional emetics; bleeding and sudorifics, suit pectoral determinations best; 
but when acute inftammation attacks the bronchia, bleeding should not be used so 
freely as when it fixes on the pleura. In the weak, the delicate, and the aged, 
bleeding should give way to purgatives and blisters over the inflamed parts, with 
the warm bath; decoctions of senega and other sudorifics; as vinegar whey; hot 
lemonade; and warm tea: 

Balsam copaiba, given in small doses, promotes expectoration; linseed tea with 
8 or 10 drops of antimonial wine may also be used for the same purpose: Calomel 
given as an alterative will then complete the cure: 

In the sub-acute form, local bleeding; cool air; silence; rest; saline purgatives 
and sudorifics, will be sufficient: 

If the head be aflrected, raising the bed or making the patient sit up, will be 
useful: 

Free purging and copious glysters, suit the hepatic, gastric, and abdominal 
determinations: The diet should be cooling and digestible, as arrow-root with 
lemonade, tapioca, sago; and this should be continued daring the recovery from 
these forms, as relapses, chronic inflammations, and dropsies of the chest often 
follow under a more stimulating- regimen: » 

Relapses are best prevented by keeping the bowels open; sustaining a slight 
affection of tiie mouth by calomel, and continuing the mild diet: 

Local bleeding over the seats of inflammation, when it does take place, will 
generally relieve it: 

The congestive form of typhus is known by the absence of the hot and dry skin; 
by the oppression, congestion, and turgcscence of the venous system in particular 
parts, and by the fluidity and dissolved state of the blood, or i^t least by the 
absence of the inflammatory buflj which occurs generally in the acute and sub- 
acute forms: 

It is also known by paleness, the bloated lividness of the face; by the anxious 
breathing; by the low struggling and variable pulse; when from the first it is 
impossible to hold up the head: the mind is dull, afiected with stupor; the patient 
has a bewildered look; the eyes glaring without redness, in fact all the symptoms 
indicating a loss of arterial action and general weakness.* 

Bleeding moderately and very early employed; the tejiid l)ath; frictions of the 
skin; calomel; purgatives; emetics and blisters, arc the proper remedies for this 
form. 

In the aged and* the delicate, venesection is improper; and in the robust, when 
by its proper use the arteries have been liberated, and the distension of the veins 
has been lessened, diflusible stimulants should be given in such doses as to excite 
the arteries moderately, and not induce inflannnatlon; a slight ptyalism will, after 
bleeding, establish a well balanced action of the blood-vessels, and prevent local 
inflammations. 

The poor, whose anxious minds, precarious, scanty and bad food, miserable 
filthy dwellings, debilitate the system, require always a more tonic treatment than 
those who live in comfort: The inhabitants of cities also do not bear depletion so 
• Arinktrong, p. b8— 171. 



TREATMENT OF CONTINUED FEVER. 99 

unequivocally exhibited. At this period of the disease, the powers 
of life may be oppressed, but it is not probable that they are yet 
much exhausted. From this they will recoil, if the oppressive 
load of the disease be quickly removed. * But blood-letting may 
sometimes be resorted to with the best effects at more advanced 
periods of the disease. Great nicety indeed is required in distin- 
guishing the symptoms that delnand it, and in apportioning the 
evacuation to the extent of local disease, and the general powers 
of the constitution. Delirium, in particular, is a symptom which 
may sometimes be alleviated by a small bleeding (as, for instance, 
to six ounces,) even at an advanced period of the disease; but, for 
the most part, it will be found preferable to employ local blood- 
letting, when the object in view is the relief of an urgent symptom. 
Of the comparative advantages resulting from general and local 
bleeding, in the continued fevers of this country, it is difficult to 
speak with precision. I have frequently had occasion to see affec- 
tions of the head, in fever, yield speedily to the application of 
leeches, where general bleeding appeared only to weaken the body, 
without influencing the local affection. Leeches I believe to be, 
upon the whole, preferable to the application of cupping-glasses, as 
occasioning less irritation. 

The appearance of the blood drawn in cases of continued fever 
varies considerably. To a certain extent, it may serve as a guide 
to us, in indicating the propriety of further depletion. It is some- 
times huffy, and the coagulum firm; but in genuine typhus the 
coagulum is commonly loose, ^ the blood thin, livid, dissolved, or 
sanious;' appearances which contraindicate the employment of bleed- 
ing. In a case of great oppression of the brain, however, amounting 
almost to apoplexy, but connected with the invasion of fever, I 
once saw the most marked good effect from general blood-letting, 
and yet the blood drawn scarcely coagulated at all. 

OF THE COLD AFFUSION. 

Cold affusion, upon which great reliance was at one time placed 
in the treatment of fever, is attended with so much inconvenience 
and fatigue to the patient, that in this climate it is now very gene- 
rally superceded by the employment of cold or tepid sponging. 
From this, in most cases, much benefit is derived. It is grateful 
to the patient; it diminishes the heat of the body, takes off that 
dryness of the skin which occasions so much irritation, and is 



well as those of the country. This applies, however, only to the poor, who live 
in filthy and close dwelling's and want wholesome food. The active, industrious, 
middle classes in cities, who are temperate, are equally robust with the same 
people in the country. C. 

* See Bateman on "the Contagious Fever of this Country," page 102; a work 
containing a most judicious exposition of the principles and details of the treatment 
of continued fever, upon which it would be difficult to improve. 






100 "TRE^S^IENT OF CONTINUED FEVER. 



^ oner 



sometimes succeeded Iwa quiet slumber, and a gentle perspiration. 
It may be repeat^4^t\^enever the skin is hot and dry, and it is 
often useful eveinyStwry advanced periods of the disease. In those 
uisite fpjj^VLpiflammatory fever which are met with in hot 
' 1^, Wi^^pjf^'ffusion, in the manner recommended by the late 
a powerful means of diminishing the high excitement 
that prevails. We may form sofne idea of this, from the well 
marked good effects of the application of cold to the head, in dimin- 
ishing head-ach, delirium, and restlessness, in the common con- 
tinued fevers of this country. 

In America the same practice is applicable. With regard to the application of 
cold water, the rule of Dr. Currie is as follows: 

In the evening-, when the exacerbation is at its height; when flushing, thirst and 
restlessness are present with a temperature above what is natural, it may be 
resorted to. It must not be used during the cold stage, or when there is a con- 
siderable perspiration. If great weakness also be present from exhaustion by 
diarrhoea, it is also improper. 

Dr. Jackson of the West Indies decides the propriety of this remed}', by the 
state of the sensibility of the sui-face. When by applying- the hand to the skin, he 
finds the susceptibility to impression deficient, and there is no internal local inflam- 
mation or congestion, he attempts by aflPusions of warm water over the surface, by 
washing the skin with warm soap and water and rubbing it with brushes, and 
putting the patient into a warm bath to restore to the surface the broken balance 
of ^the excitability, thus to excite the skin. If the action of the blood-vessels be 
either below or above par, violent or prostrated, he considers the use of cold 
aff'usion improper, till bleeding, purgatives, and other evacuations in the former 
case, and the warm bath, &:c. in the latter, have rendered it proper. Dr. Currie, 
on the contrary, uses it in the first stage of fever, when the temperature is above 
98° without evacuations. 

In the application of the remedy, though its virtues from the prejudices of the 
people have not been fully made known, it is certain that in the regular continued 
fevers of northern and temperate latitudes, both typhoid and inflammatory, with a 
hot skin, where there are no local determinations, it is valuable, and often cuts short 
the fever. In hot climates the most ardent form of bilious fever is often mitigated 
by this plan. Sailors raging with delirium have been instantaneously restored to 
reason by jumping into the sea. In warm climates, where fevers are attended with 
violent sudden blazes of re-action, or equally marked and sudden evidences of 
prostration, it is often necessary to temper its use with more discretion, viz. by 
venesection, &c. when tlie fever runs high, and the use of tlic warm bath, frictions 
to the skin, &.c. as above stated, when the blood recedes from the surface, and 
appears in inflammations or congestions of the internal organs in a prostrated state. 
So variable indeed is the system, in warm climates and also sometimes in hot 
seasons of our own latitude, that bleeding will often be found necessary at one 
time, when shortly after, stimulants Avill be proper. 

In applying cold to tlie surface, therefore, it is necessary to recollect, that it 
admits of various degrees. It may be used by cold afi'usions of two of three gal- 
lons, between 40° and 60° of Fahr. at a time, dashed over the body and frequently 
repeated, and then removing the patient to bed; or more gradually from a watering 
pot, or by sponging the body with cold water, or, to allay the prejudices of friends, 
with vinegar and water, or brandy and water, wliich cools more by evaporating 
more rapidly, or salt and water, or by exposing the patient to a current of cold air. 

Salt water was preferred by Dr. Currie, from its stimulating cftccts upon the 
skin, by which he thought the debilitating effect of the cold was prevented: it is 
also more grateful to the patient, and it may be applied to the surfiice for a greater 
length of time with less hazard; a person preserves his colour and the brightness 
of iiis eye longer in salt than in fresh water: vinegar and water is more expensive 
than salt and water; simple cold water, will, however, answer every purpose; though 
if the case is doubtful, tho salt water should be used. 



TREATMENT OF CONTINUED FEVER. 101 

The effects of this plan, if used on the first or second days of the disease, is to 
cut short the fever; and if it is used afterthe third or fourth, it mitig-ates its violence 
and shortens it. It has been of use even on the eleventh, twelfth, or thirteenth 
day; if the debility be too great, sponging- the surface may be used in its stead. 

In the irregular, chilly, feverish and forming stage of typhus, \Vhere nausea, 
debility, weariness, paleness are present, the warm bath is preferable. It then 
stimulates and equalizes the circulation, when the cold would endanger life. 
United with tepid drinks, as, barley water or gruel, a gentle sweat is produced; the 
tone of the stomach is restored, and the patient feels invigorated. In this stage, 
emetics, purgatives, and the warm bath do all that can be expected, and often cut 
short the fever. It must here be recollected that we are speaking of the warm 
bath, which, as above stated, is applicable to states of the system in wliich the tempe- 
rature is below natural. The tepid affusion, liowever. Dr. Currie found to be appli- 
cable only to those cases, in which the cold bath was, as it reduced the tempera- 
ture in the same manner, and in the same degree. The heat to use it, must be regu- 
larly above natural, and even in cases where it did not exceed 98° it reduced the 
temperature to such a degree, as to endanger the safety of the patient. Indeed 
Dr. Currie thought that the tepid water lowered the temperature of the body more 
rapidly than the cold water. The tepid differs, however, from the cold affusion, 
in being less permanent in its effects, as he never saw the tepid affusion stop the 
progress of fever. The tepid or warm bath, it must then be recollected, are proper 
when the temperature is below natural; the tepid affusion only when it is regu- 
larly and steadily above natural. The reason, why the tepid affusion is more debi- 
litating than the warm bath, is the evaporation attending the former, which 
abstracts the heat more rapidly than even the cold affusion. Rubbing with brandy 
or any spirit, as being more volatile than water, is liable to the same objections. 

Exposure to cold in the chilly stage of typhus, is always improper, as it may in- 
duce internal inflammation of the head, lungs or kidneys. Tlie room, for this reason, 
should be about 60°. The cold affusion is not always admissible in the inflamma- 
tory typhus; thus, when, though the heat is above natural, the skin, particularly 
where the abdominal viscera are inflamed, is found to be moist, and the patient is 
chilly; the warm bath is then preferable to the cold. Dr. Currie advises ablution 
with water, from the temperature of 7S'^ to 87°; when from the lowness of the 
action, or the continuance of the disease, there is danger of injury. However, it is 
by its effects upon the blood-vessels that its value is estimated; and as the author 
remarks, it is certainly in some cases not only applicable to the early stages of 
continued fever, whether of a high or a low grade; but it has succeeded in America, 
even in the advanced stages, when the heat in the after part of the day is con- 
siderable, when delirium is present, with coma and subsultus tendinum, if the 
pulse still possess some strength; and even though it should intermit,* It should 
be repeated as often as the surface becomes hot and dry, and the thirst becomes 
considerable; observing always, if the feet or other parts of the body be cold, to 
restore the equilibrium, first by immersing them in warm water, by frictions, &c. 
and then seating the patient in a tub, to use the cold affusion, which may be gra- 
duated from simple sprinkling, to pouring a few quarts or gallons over the parts 
which are preternaturally warm. The thirst is at once removed, free perspiration, 
comfortable feelings, and recovery from stupor, are the results. It may occasionally 
from debility, be necessary to administer stimulants; as wine, brandy, to give tone 
to the circulation; the cold affusions have then been followed by the best effects. 

The heat of the skin sometimes proceeds from too much bed-clothes, from close 
confined rooms, hot drinks, excitement from worrying visits when the power of 
the system has flagged; it will therefore be requisite to ascertain exactly its true 
state by a deliberate examination before it be used. To sum up; it may be applied 
in all stages of typhus, when the heat is steadily and regularly above natural, and 
there are no local determinations. 

Pain in the head, delirium, with languid circulation in the extremities, are often 
relieved by ice, and by cold water applied by cloths to the head, and warm water 



* See Medical Recorder, Vol. VII. p. 384, for Smith's observations on typhus. 



102 TREATMENT OF CONTINUED FEVER. 

to the feet. Blisters to the head or back of the neck can only be useful in relieving 
these symptoms, when the excited stag-e is nearly passed; they are then of benefit. 
They often procure sleep by translating- the excitement to the surface. C. 



EMETICS. 

When the opportunity offers of administering remedies in the 
first days of the fever, an emetic should never be omitted; 'after, 
however, the free use of the lancet, if the S3^mptoms show a deter- 
mination of blood to the head, as apoplexj^ has sometimes been the 
result of its neglect. ^ The following draughts may be recommended 
for this purpose. 

R. Pulv. Ipecac, ^i. R, Pulv. Ipecac, gr. xvi. 

Aq. Menth. Sativ. 5x. PLdv. Antim. tartariz. gr. i. 

M. f. haust. Aq. puleg-. 5i. 

M. f. liaust. 

Besides clearing the stomach, an emetic seems to possess some 
power of determining the blood to the surface, and in this wzy 
relieving the oppression of internal organs. " They are particu- 
larly useful on the onset of the disease, ^vhen there is paleness of 
the face, weariness, dejection, debility, coldness, succeeded by 
slight fevers, nausea, weight about the precordia, giddiness with a 
low pulse; followed immediately by a purgative of calomel and 
jalap in this stage, they sometimes cut short the disease at once. 

In the inflammatory forms when the tongue is loaded with a 
whitish or yellowish fur, Avith uneasiness at the stomach, after a full 
bleeding, emetics are always useful. '^ 

They also, by discharging- the contents of the stomach, prevent diarrhoea, in the 
latter stages, when the system is too much debilitated to bear active ])urging'. 
Sydenham found that an active emetic, given in the continued fever of 16(^1, &c, 
prevented many serious symptoms in the course of the disease; the principal of 
which, Avas a weakening looseness in its latter stages. If an emetic was not given, 
he found that the patient suHcrcd materially from this aficction, which could not 
afterwards be controlled by astringents, or any other remedy: but immediately 
after its operation, when given early in the disease, he immediately recovered 
from the nausea; blackness of the tongue; anxiety and restlessness, with which he 
had before been affected; and ixS soon as the fever commenced, the lirst thing he 
did was to bleed and then give an emetic; he g'ave it, however, also, at a late 
period, provided the patient was able to bear it, even on the twelfth day of the 
disease. In general, the sick bear emetics bctterthan jiurgcs, or any other deplet- 
ing remedies, when the tongue is foul;* in the cases of children, ipecacuanha is to 
be preferred to any other emetic, from its mildness. 

Sometimes they are given in small doses, so as to nauseate in the first periods, 
when they lessen the fever by purging or sweating: they may even be g'ivcn in a 
more adv:niccd stage of the disease, ut the conunencement of the exacerbations; 
as they weaken, if much g0(Kl is not done early they should be omitted.f They 
may be combined with* the saline medicines mentioned below, in any degree, to 
produce either the emetic, the sudorific, or the purgative effect, according to the 
case. C. 

• Rush's Sydenham, p. 17, note. t I'li'^'P. P- 246—7. 



TREATMENT OF CONTINUED FEVER. 103 



SALINE AND ANTIMONIAL MEDICINES. 

Saline medicines, such as the citrate of potash and acetate of 
ammonia, are very useful throughout the early and middle periods 
of the disease. 

R. Sub-carbon, potass, gr. xvjjj. 
Slice. Limon. ,5ss. 
Spirit, myrlstic, gtt. x. 
Aq. distillat. ,^vi. 
Sacchar. alb. 9j. 
M. effervescent, linit. fiat haust. tert. quaq. hor. repetend, 

R. Liq. Ammon. Acetat. ^iii. 

Aq. Month. Sativ. ^vi. 

Syrup, aurant ^i. 
M. ft. haust. quart, hor. repet. 

R. Mist, camphor. ,^ivss. 

Liq. Ammon. acetat, ^iss. 

Vin, Antim. tartar, ^ii. 
Fiat. mist, cujus sumat ^i. quart, quaq. hor. 

Pringle thought highly of the spirltus mindereri, rendered slightly alkaline by 
the addition of a small quantity of the carbonate of ammonia, after the spirit was 
formed; and when there was local pain, he speaks of the addition of the syrup of 
squills, instead of the ammonia, as being valuable. 

They allay thirst, and appear to exert some influence in con- 
trolling the action of the heart and arteries. They should consti- 
tute the basis of our treatment in most cases j and in the milder 
forms of simple fever, little else is required. 

Antimony was long distinguished as di febrifuge of great virtue; 
but latterly an opinion has prevailed, that its efficacy in the treat- 
ment of fever is rather a matter of tradition than the dictate of 
experience. To this I cannot subscribe, having had frequent oppor- 
tunities of satisfying myself of its claims upon our confidence. It 
occasionally acts upon the stomach and bowels; but independent of 
this, antimony proves useful in fever, apparently by some power 
of diffiising and equalizing the circulation. The oxyd, as we find it 
in i\\Q pulvis antimonialis of the London Pharmacopoeia, is, I 
believe, the best form in which it can be administered. In combi- 
nation with small doses of calomel, and given either at night, or 
every six hours, according to the urgency of the symptoms, its 
efficacy is often manifested by an improved appearance of the 
tongue and alvine evacuations. 

' In the highly inflammatory form, after the hard, bounding, 
frequent, and tense pulse has been reduced, a solution of six grs. 
of tart, emetic to the quart of water, given in the dose of a wine 
glass full every four hours, will prove a valuable sudorific. Its 
advantages are, that it can be made to vomit by giving it in the 
same dose every ten or fifteen minutes, or act as a purgative by 
administering it every two hours; graduating it according to the 
case. ' 



104 TREATMENT OF CONTINUED FEVER. 



OF PURGATIVES. 

No doubt can be entertained respecting the propriety of exhibit- 
ing purgatives during the whole course of continued fever. For 
this purpose, the following draught may be recommended. 

R. Infus. Senn. Compos, ^x, 

Magnes. Sulphat. 5"* 

Tinct. Senn. 31. 

Syrup. 51. 
M. Fiathaust. 

Combinations of jalap or rhubarb with calomel, as the following, 
are well adapted for the commencement of fevers. * 

R.Pulv. Jalap. 9i. 

Hydrarg-yr. submuriat. gr. iv. 
M. ft. pulv. 

R. Hydrargyr. submuriat. gr. ii. 

Sacchar. alb. gr. iv. 
M. f. pulv. 

< In typhus castor oil is useful; as it maybe made to operate 
either as a laxative or a purgative, according to the case.' 

Purgative medicines are serviceable in different ways. They 
diminish, in an early period of the disease, the mass of the circu- 
lating fluids; lower the tone of the whole system; and expel from 
the body aliment, the fermentation or putrefaction of which would 
necessarily aggravate the sufferings of the patient. At a later period, 
they evacuate those morbid secretions of the liver and bowels, 
which are continually taking place; and the lodgment of which 
would tend greatly to oppress the nervous system, and, therefore, 
increase the danger. It is not to be imagined, however, that the 
administration of purgatives in fever requires no particular caution. 
It is indispensably requisite to watch the degree to which the abdo- 
minal viscera are affected, and cautiously to refrain from them (or 
at all events from the most active of them, such as, jalap, colocynth, 
or calomel,) whenever inflammatory action is present, or any 



* See "Observations on the utility and administration of Purgative Medicines in 
several Diseases," by Dr. James Hamilton; a work of great merit. 

* In synocha where the fever runs high with local pains, pulse tense, strong, 
and hard; skin hot, &:c. the purging should be cojiious, ;ind repeated every day, 
after full bleeding as before advised. Tiie fever under this treatment will soon be 
suspended: a slight affection of the mouth with mercury, will render the cure 
more certain: It may be effected by giving a grain of calomel every night and 
morning, or four grains of the blue pill, and rubbing into the surface of the thighs, 
the size of a nutmeg of strong mercurial ointment twice a day, to produce as soon 
as possible the result; as soon as the mouth is artectcd, the mercury should be 
suspended, and the thighs washed: A gentle ptyalism is of the utmost conse- 
quence in typhus as well the remittent forms, particularly in the south: it relieves 
iit once, and immediately on its taking place.' C. 



TREATiMENTOF CONTINUED FEVER 105 

disposition to it, as evinced by diarrhoea, or tenderness of the 
abdomen.* 



* The following" mode of treatment of typhus, by Dr. Miner, abridged and 
extractedf upon his Essay on Fevers, will well deserve the attention of the pro- 
fession. 

** When called to a patient who has the precursory symptoms of fever, or even 
if he has advanced two or three days into the preparatory stag-c, after we have 
investigated the nature of the case, the first inquiry is, whether there be a rational 
prospect of breaking up, or procuring" a resolution of the disease^ if tliere is, to make 
the attempt is of immense importance. The means sliouldbe such as can be most 
conveniently employed, be liable to the fewest accidents in their execution, and 
though they might happen to fail of breaking it up, they should be such as will 
best moderate its violence, shorten its duration, and at the same time put the 
patient in the least danger of sinking at a critical period, and, also, best prepare 
him for the subsequent appropriate remedies. M'hen the fever has a typhoid 
character, sloav and moderate purgi>'g with calomel, answers the indications 
just mentioned, better than any other method. It is the only one, of all the com- 
mon devices for breaking up fevers at their access, which in my practice, has been 
attended with any degree of certainty. I'he calomel, mixed with any mild syrup, 
but not in the form of pill, should be administered in small doses — from two iojive 
grains, every two or three hours, according to the circumstances of the patient, till 
sufficient catharsis is produced. If possible, the calomel should be given in such 
doses, and at such intervals of time, as to be retained in the stomach and bowels twelve 
hours, before it produces its operative effect. But if catharsis does not take place 
in eighteen hours at farthest, it must be assisted by castor-oil, or some other mild 
vegetable purgative. At the same time, it is proper to pursue a moderate diaphoretic 
regimen,- such as the pediluvium, tepid aromatic, and diaphoretic drinks, fomen- 
tations and sinapisms, or epispastics, as the local symptoms require. When the 
pain in the head is violent, a blister to the forehead wWl not only be of essential ser- 
vice in relieving this particular symptom, but will very mucli assist the effort at 
breaking up the disease, by superinducing an additional new action. W^arm 
bathing is also an excellent adjuvant in the severer cases. In putrid fever, when 
the heat is above the natural standard, and the skin dry, we may also resort to cold 
affusions, with a cooler regimen, there being nothing in the calomel practice to 
interfere with its use, in truly hot cases. Cold affusion is, however, with us, rarely 
indicated; as in the majority of our fevers, which are decidedly oi'the nervous type, 
the heat scarcely exceeds the temperature of health, and is often below it, during 
their whole progress. If the catharsis inchne to be excessive, it must be promptly 
checked by opium; if too sparing, the vegetable cathartic is to be repeated. When 
tlie patient has been previously purging himself, injudiciously, with an ill chosen 
article, or the case is attended with a diarrhoea, or there is reason to suppose tliat 
the calomel will pass rapidly through the bowels, or operate harshly, or even if 
there is much irritability of the system in general, it requires a single medium ca- 
thartic dose, with a sufficient quantity of opium, to stay it, at least, for twelve or 
fifteen hours. For a general rule, all the anomalous cases of simple fever, especially 
those of the low and simple kind, Which there is reason to apprehend might ter- 
minate fatally in one week, unless prevented by art, require opium to be combined 
with the calomel from the very access, provided any evacuation is admissible; nor 
are they safely managed, unless the patient is kept uniformly and perseveringly 
under the influence of opium, to the termination of the disease. 

" There is something peculiar and specific in the operation of calomel, differing 
from every other medicinal agent; and the more slow in its operation, to a given 
point, the more obvious is this difference. Its effects upon the stomach, small 
uuestines, lungs, liver, spleen, pancreas. Sec. have long been well known and 
acknowledged, and either from these causes, or something not yet ascertained, its 
counteracting effect at the access of febrile diseases, under suitable management, 
is preferable to every other known article. Its moderate use, in small doses, during 
the first stages of fevers, for the purpose of changing action and preparing for \ 
1 Bv the venerable Thacher . see his Moriern PracUce, p. 245-?2, 

14 



106 TREATMENT OF CONTINUED FEVER. 

Ill typhus fever wlien the skin is hot and dry, the arteries turgid, the evacua- 
tions may be free and the use of active cathartics, will be advisable, particularly 
as the bowels are often torpid: A tenesmus, diarrha-a, or g'riping- indicate their 



subsequent supporting" and tonic course, has long- been established, and rests on 
the liighest testimony. No one article so certainly counteracts and lessens morbid 
action, equalizes the excitement, and prepares the patient for the use of tonics. 
Judiciously used, it overcomes the irritability of the stomach, on the one hand, or 
moderates the torpor, on the other, Vk'hich would otherwise prevent their success- 
ful employment, and produces a favourable state of the skin, and other excretory 
organs. By this management, the patient is fitted for the bark and other tonics, 
better and earlier than in the usual way. Indeed, whether the bark is advantageous 
at all, depends almost entirely on the first week's preparation. To a neglect of this 
particular point, we chiefly owe the various and opposite testimony, with respect 
to the efficacy of this important article. I have never had a case of re^u/ar simple 
fever, the very mildest excepted, in which the bark and opium might not be used 
with obvious benefit, during the stage of exhaustion. By the judicious treatment of 
the disease, in its first stages, with calomel, all the desired preparatory effects are 
produced, without materially diminishing muscular or arterial strength, or wasting- 
the vital powers. However, the object is not merely to prepare the system for the 
subsequent supporting treatment, in order to sustain the powers of life under a 
protracted disease. We usually obtain a complete resolution, and thus break up the 
disease itself immediately. It is confidently believed, however surprising it may 
appear to those who have not witnessed the fact, that this simple process oi slowly 
and moderately purging with calomel, when employed sufficiently early, does not 
fail in more than one instance in ten, of breaking up the disease at its very com- 
mencement. In the whole course of my practice in [regular'] typhus, of all who 
have applied within the first forty-eight hours after the obvious access of the dis- 
ease, two cases only have proved fatal; and I am pretty confident, that not one has 
failed, in which the patient had not been tampering with emetics or cathartics, 

Erevious to my being called. When from these or other causes, we have failed of 
reaking up the disease, the remaining preparatory treatment for the first week, 
demands our attention. 

" Whatever may be the opinion with respect to critical days, it is certain, that 
all our late typhoid fevers have very regularly observed weekly, critical periods. It 
is an old, and very just remark, that in all regular diseases of this description, they 
are generally but little benefited by the bark, and articles of a similar tendency, 
till after a prominent critical, or semi-critical change; that is, not until ?norbid irri- 
tability of the stomach and bowels, on the one hand, or torpor on the other, is overcome, 
local pains, and other urgent symptoms, relieved, and sometimes /??. every twenty-four 
hours at least, the tongue is moist, and the skin and other excretories are free. So 
imperative is this rule, that I never knew a physician, who [in a case of regular 
fever] was daring enough to violate it. There are various means which are adopt- 
ed for the purpose of producing this particular state of the system. This kind of 
crisis, however, by the usual management, does not generally take place until the 
end of the second week, when the patient is too frequently so much exhausted, that 
tonics are apt to produce very little effect, or the system is still so irritable, that 
they cannot be borne at all. But it very certainly occurs, at the end of the first week, 
and occasionally some days earlier, especially in the more severe and rapid cases, 
when the following alterative course is properly executed. Calomel in small 
doses, united with opium sufficient to stay it upon the bowels, and also, sufficient 
to allay other irritation, and if the skin inrline to be dry, and the heat be much 
increcused, witli ipecacuanha, should be a(hninistered,as a preparatory course, during 
the first week. But in most of the phlegmasia-, and in many low and irregular 
cases, the partial crisis, or semi-critical change before mentioned, is produced, and 
the system is fitted for tonics, in a much shorter period, ^yhen this happens, wc 
must enter immediately on the supporting course, and except in a few obstmale cases 
of local inflammation^ inManlly suf<pcnd the calomel. It requires as much judg- 
ment, to know ujhta to abstract this article, as to know how to administer it at first. 
This compound of calomel, opium, and (when necessary) ipecacuanha, in order to 



TREATMENT OF CONTINUED FEVER. 107 

xise. These symptoms have been supposed fatal; and they often are so because 
tliey have deterred from the free administration of purg-atives: under their use, the 
heat of tlie skin, and the morbid force of the pulse abates: mild laxatives in these 



produce its full effect, should be f^iven at short and rarular intervals, so that the 
system may co n.staiif 1 1/ he kept under the combined eHcct of the whole of the arti- 
cles. Each succeeding" dose, therefore, must be administered a little time before 
tlie effect of the preceding has ceased. Calomel in this form, except in a very few 
moderately torpid cascs^ wliere not previously used, is probably never serviceable, 
as an alterative, after the first week; nor, a few local inflammations excepted, even 
r.fter the semi-critical chang-e is produced, however early in the disease it may 
have taken place. This process is much assisted by infusions of serpentaria, and 
other aromatic and diaphoretic drinks, and the various circumstances, which belong 
to the proper moderate diaplioretic reg-imcn. But if we are not called till near the 
end of the first week of simple fever, calomel should not be employed, except as 
a slo«- and moderate cathartic; for in this late stage, it is nearly imjjossible to touch 
the moutli, or to affect the system; and it is liable, when it has any influence, 
instead of diminishing', to coincide with the existing morbid action, and then to aggra- 
vate the very symptoms which it was intended to counteract. 

•' The minutest circumstances are often necessary to be observed, in order to 
obtain the full effect of an important article. If they are overlooked, its operation 
is defeated. Thus in highly sthenic disea-^es, calomel will not produce its alterative 
effects, unless the system is first thoroughly reduced, by depletion and evacuation. 
In like manner, in the loivest typhoid diseases, these effects cannot be produced, 
luiless the system is first raised by alcohol and opium, or what is perhaps preferable, 
by capsicum, aromatics, and acrid stimulants, it is by no means intended, ever to 
produce complete ptyalism, or, strictly speaking-, any ptyalism at all. In this case, 
as probably in all others, this effect is to be avoided, if possible. Not that any 
material or permanent evil is the consequence; but it is productive of considerable 
temporaiy distui-bance, without being in itself of any ser^■ice. The cupreous taste, 
the slightest distension of the gums, or sloughy whiteness, or erosion of their 
margin, and soreness of the teeth, the most moderate degree of the peculiar fleecy 
appearance of the tongue, and fetor of the breath, which are among the first visible 
effects of mercurials, will be amply sufficient. This is the state which it is desirable, 
the very low cases already excepted, to keep up during the first week, or till the 
sub-critical change supervene, liy this plan, the patient is prepared for tonics, a 
week earlier, than by the common practice. 

Before dismissing the subject of calomel, it is necessaiy to enforce one important 
point, with respect to the administration of this article, \t[z. That there is no cer- 
tain dependence to be placed upon its use, either as a sloiv and moderate cathartic, or 
as an alterative, unless the patient will submit to an appropriate diaphoretic regimen. 
He must confine himself to his room, and in many instances to his bed, and at the 
same time, use tepid aromatic and diaphoretic drinks, light liquid food, such as 
broth, milk-porridge, aiTow-root, or the lighter vegetable and animal, mucilaginous, 
and gelatinous preparations. Pediluvium, or warm-bathing, sinapisms, and in many 
instances, epispastics, are indispensable auxiliaries. Having completed the pre- 
paratory course, and entered upon the tonic and supporting plan, at least a week 
earlier than usual, we are enabled to carry the patient safely over the dangers 
attending the most important critical periods. 

Although the main intention of these remarks, is to point out a method of treat- 
ment suited to the first iveek, or to the forming and preparatory stages of regular 
febrile diseases, as well as to demonstrate the practicability of breaking them up, or 
of producing a resolution at their access, and particularly to establish definite and 
precise rules for the use of calomel, yet, I cannot forbear making a few remarks 
upon the method of support, which it is necessary to pursue, during the continuance 
of the disease, or the stage of exhaustion. 

Moderate doses of the decoction and tincture of the bark, given at short intervals, 
and when the skin inclines to be dry, combined with serpentaria, or similar dia- 
phoretics, mineral acids, wine, and epecially Opium in small doses, every three or 
four hours at farthesty and even every hour, in the lowest cases, constitute the 



108 TREATMENT OF CONTINUED FEVER. 

cases have no effect. Frequently in typhus fever the stools are black, foetid, and 
large, and are attended with the worst symptoms of the last stage, as low delirium, 
subsultus tendinum, dry and furred tongue, weak and feeble pulse. Purges freely 



most successful method oT supporting the system. In very low cases, diluted alcohol 
is preferable to wine,- and Fowler's mineral-solution, in doses from five to eight 
minims, or at any rate, in a quantity short of the nauseating point, should be 
administered every four or six hours. Where the bark is worn out, or when it is 
rejected by the stomach, this article is a most excellent substitute; but whoever 
uses it, without combining it with opium, will, most assuredly, be disappointed in 
its effects. Slow and moderate purging, (when it fails of removing the disease) 
is but a good beginning of the alterative process, and rarely is sufficient, of itself, 
to produce the semi-critical change, so that the patient can be profited by tonics, 
unless it is followed, a few days, by a suitalile course of calomel and opium. Nor 
is the disease commonly more than half througli, when the sub-critical change has 
commenced. No time, therefore, is to be lost. The supporting course is now to 
be entered on with decision, and pursued with energy and perseverance; for if the 
proper time for administering tonics is passed bi/, there of ten arises such an irritahility 
of the system, as in a great degree to preclude their use. More inconveniences pro- 
ceed from indecision on this point, than from almost any other. Besides, the acci- 
dental symptoms w\\\c\\ are ever liable to be met with, at the critical periods, are to 
be treated with the greatest promptness. Vomiting', diarrhoea, &c. must be immC' 
diately suppressed ,- not by emetics and cathartics, but by full doses of opium, blis- 
ters to the stomach, and other auxiliaries. Metastasis of the diseased action to the 
brain, lungs, or any other vital organ, admits of no relaxation in the general treat- 
ment; but often requires a vast addition to its force and strength, combined with the 
most vigorous and extensive application of blisters over the parts, with other topical 
remedies. As soon as the brain is known to be much affected, the upper part of 
the head is to be shaved, and a large epispastic applied; and tincture of stramo- 
nium is often an important auxiliary. Charcoal, capsicum, and oil of turpentine 
may often be used with success, in tympanitic abdomen. The introduction of a 
tube into the rectum, frequently removes this troublesome symptom. The dan- 
gerous and troublesome coma, which often occurs in the last stage of fever, is more 
effectually overcome, and the counterfeit torpor, in this stage of low typhus, is 
more easily counteracted, by the regular administration of opium and alcoliol, than 
by any other means whatever. Their occurrence is more rare, when these articles 
have been previously used, than under tlie common treatment. But to produce 
its full effect, it is absolutely necessary, that each succeeding dose of opium should 
be administered before the exciting effects of the former have passed by. Much atten- 
tion is necessary to tjiis subject. Wiien managed in this way, opium becomes the 
most efficient and safe exciting power of the whole Materia Medica. By an 
unsteady and in-cgular administration, and at too long intervals, or in improper 
doses, it is, on the other hand, one of the most precarious. The true standard for 
the administration of opium, as a supporting agent, is to increase the dose, until 
the febrile irritation, restlessness and anxiety, are subdued, and tremors and sub- 
sultus controlled. In the severe cases, coma supervenes upon this state of irritation, 
to a much greater degree, where narcotics have not been employed; and when 
they have been previously used, and are abstracted, under the false notion that 
they produce this symptom, it is invariably aggravated. It is not the opium, but 
the manner of administering it, which produces disturbance and troublesome 
secondary effects. As a general rule, to overcome irritabllit}-^, with subsultus, 
spasms, and its other various symptoms, o])ium should be given in full doses, at 
intervals of three or four hours; for when the dose is not sufficiently large to subdue, 
it seems to increase these symptoms. But when it is used as a supporting agent, 
it should be administered in small doses, once in two hours; and in extreme cases, 
it is sometimes necessary to repeat it every hour. 

It may be proper also to remark, in this place, that where debility is attended 
with irritability, ovn- principal reliance is to be placed upon opium; but where 
debility is attended with torpor, our dependence must be placed chiefly upon 
Ivttac, capsicum, and other acrid stimulaiits ; yet opium, in appropriate doses, is 



TREATMENT OF CONTINUED FEVER. 109 

•given abate these symptoms, and invigorate the patient.* In the commencement 
of the fever, when the excitement runs high, tlie mercurial and sahne cathartics 
are best.f Active purging- also prevents retention of urine, which always aggra- 
vates the symptoms, and may require the use of the catheter: a slow dropping of 
urine from the penis sometimes deceives the patient, when the bladder is nearly 
ready to burst. In children this is to be particularly attended to: the protrusion 
and tumor of the hypogastric region will generally determine the necessity of the 
catheter. The accounts of attendants are not to be relied on, in this matter, as 
from its continual dripping they often suppose the urine is sufficiently evacuated 
when it is not. 

Sometimes in mild continued fever, when the pulse is soft, a diarrhoea appears, 
which exhausts the patient without proving critical: after a purge of calomel 
and rhubarb, senna and manna, or epsom salts, it should be checked by the use 
of subcarbonate of potass, ^ss. with eiglit or ten drops of laudanum; or gss of 
chalk occasionally with mint water, and eight or ten drops of laudanum, or by 
small doses of antimonial wine and laudanum, to determine to the surface.^ C. 

CORDIALS. 

The great weakness which prevails in fever, naturally led to the 
employment of cordial and tonic medicines, more particularly wine, 
ether, camphor, musk, bark, and nromatics; but it is now gene- 
rally acknovvdedged, that the indiscriminate use of stimulant reme- 
dies in fever, is highly pernicious; that they have a tendency to 
aggravate many of those local determinations, from which danger 
is chiefly to be apprehended; and, therefore, that their employment 
is to be regulated by circumstances, no less than that of blood- 
letting. The period of the disease, the particular situation in which 
it appears, its exciting cause, the age, constitution, and former 
habits of the patient, are of course to be taken into account; but we 
are chiefly to be guided by the character of the symptoms, and 
the effects of the remedies. 



essential in either case. Alcohol, mineral-solution, oil of turpentine, and a frequent 
succession of blisters, are beneficial in severe cases of both varieties. 

But medicine, alone, is not sufficient to cure any protracted disease. It is indis- 
pensable that the patient should be regularly furnished with suitable food, which 
is both nutritious and easy of digestion. Gelatinous and mucilaginous preparations 
are far preferable to solid substances. During the stage of exhaustion, from half an 
ounce to an ounce or two, of broth, milk-porridge, or arrow-root, &c. should be 
taken a dozen times in twenty-four hours, with the same regularity as the medicine. 
Milk, with one third lime-water, is good food, when the bowels are too soluble. 
In convalescence, oysters, and the soft parts of shell-fish, answer the best purpose, 
for the stomachs which have been accustomed to them in health. 

* Hamilton. f Philip, p. 263. 

\ When cough occurs in the more advanced stage of the fever, oppression, and 
tightness at the chest; mucilage of liquorice, with small doses of antimonials, and 
paregoric, will reheve by determining to the surface. Mucilage of gum-arabic; 
flaxseed tea; spermaceti ^iss, rubbed up with the yolk of an e^^, to which may be 
added ^iiss of vinegar of squills, and v^ of mint water, will form valuable expec- 
torants. 

When the stomach is nauseated, a few drops of laudanum and peppennint; or a 
draught of soda water; of seltzer water; or a solution of carbonate of potash, ^ii to 
six oz. of water; and after it a table spoonful of vinegar or lemon juice, will gene- 
rally quiet it: a purge of ,^i glauber or epsom salts, with a gr. of tart, emetic, 
speedily operates as a purgative, and cures the nausea, when it depends upon an 
accumulation of morbid matters. C 



1 10 TREATMENT OF CONTINUED FEVER. 

1. In the state of true collapse, marked by cold and clammy 
s\vcats, a ''quick faint voice and indistinct articulation; respiration 
short, temperature variable; weak and sinking pulse, and pale 
urine; skin shrivelled; cough; fcetid perspiration; sliding down in 
the bed with the knees drawn up to the body;" feeble wavering 
pulse, oppressive breathing, the supine posture of the patient, and 
a moist, brown, "dry," and loaded state of the tongue, stimulants, 
especially wine or brandy, are not only beneficial, but absolutely 
necessary. Such symptoms are clearly indicative of a failure of the 
powers of life, and unless stimulants " and tonics" are duly sup- 
plied, in quantities proportioned to the exigences of the case, the 
patient rapidly sinks. 

Great evacuations of all kinds are then improper; for a strong" purg-e will often 
produce death: the bowels however should be kept moderately open. 

Sometimes they become excessively loaded with foeces from neg-lect of purging 
in the first stage; inducing delirium, stupor, flushed face and a quick pulse; the 
use of purgatives, combined with tonics and cordials, are then valuable: as rhu- 
barb, tincture of jalap, with quinine, whey, &c. and after the purgative operates, 
an opiate. Sometinaes the stools in this stage are black, foetid, and loose, with 
blood and slime: cathartics taken in the same manner relieve them. C. 

BARK, &:C. 

• Those cases of typhus which are accompanied by petechia, or 
the large livid blotches called vibices, in short, by what we have 
denominated the symptoms of putrescency, are benefitted by the 
steady and moderate exhibition of wine, bark, and aromatics; 
" particularly if the petechias are not of a scarlet, but dark brown 
colour when they at first appear; are attended with discharges of 
blood from the gums, nose, bladder, bowels, or skin; then evacua- 
tions of all kinds are hurtful, because the system is nearly ex- 
hausted." 

The sulphate of quinine in doses of three or four grains every two hours; or the 
cold or hot infusion or decoction of bark, or of tlic scrpentaria, arc proper to sup- 
port the strength in tliis stage, as thoy best agree with the stomacli: They may be 
combined with the sulphuric, or muriatic and oxymuriatic acids in the dose often 
or fifteen drops, which will increase their effect: Iftlie medicines disagree with 
the stomach, the infusions of cascarilla of columba, or of quassixi, may be sub- 
stituted: ■/ 

Fowler's solution of arsenic in the practice of Dr. Ferriar succeeded in the last 
stage oftyplius, when other tonics had no e fleet: It was prescribed during the 
fever, without regard to cough, dyspncea, or any other local symptom: Dr. Thomas 
speaks highly of it; and I have seen it used in the Fennsylvania Hospital with the 
best effects: 

Laudanum, infusion of orange peel, may be used to prevent these medicines 
affecting the stomach. These stimuli must be assisted by others which may be 
selected, accoi'ding as they agree, as carbonate of ammonia in doses of three grains 
every two hours, — camplior dissolved in milk or reduced to powder by rubbing in 
a mortar, previously wetting it with spirits of wine, in the same quantity — ether — 
opium — or what is much better, camphor and opium combined. Camphor calms 
the low delirium, excites a glow on the skin, and gives a steady and cordial tone 
to the system. It may be given in union with the bark, and has little effect on the 
pulse. It was formerly given in Germany combined with vinegar. Musk is also 
a vahiable remedy: like camphor, it gives tone withotit increasing the pulse or 



TREATxMENT OF CONTINUED FEVER. | 1 1 

heat of the system, which opium, wine, 8cc. are too apt to do. Castor was formerly 
much used; it is g-iven ill the dose of five grains every two hours: 

Madeira wine in wine whey or with milk, may be given every two hours in the 
quantity of half a pint in twenty-four hours to an adult. Brandy and the stronger 
wines sometimes excite too much, and exhaust the powers of the stomach: beer, 
porter, claret, or cider, will then be useful: brandy, wine, &C. may be given in 
enema: In Tennessee, in the low state of typhus, this practice has been useful: A 
table spoonful of yest given every two hours, is also valuable: it nourishes, and. its 
fixed air is tonic and stimulating to the system: 

The diet should be composed of animal broths, sage, tapioca, an-ow root boiled 
in milk, given in small quantities, and often repeated: in particular, the stomach 
should always have something in it, from the danger of excessive debihty: 

Fresh air in this stage is also highly tonic and invigorating. Dr. Hennen observed 
in Spain, that during- sultry weather when typhus prevailed in the hospitals, that 
when the weather became cold, the sick were so invigorated, that even venesec-' 
tion became necessary, though before the lowest symptoms of typhus prevailed, 
which could only be treated by stimulants: 

The sleep should not be inteiTupted except to administer the diet; to encourage 
it, porter, the tincture of hop, laudanum with camphor, will be proper. In this 
low state every thing that supports, and gently stimulates, is useful: Gestation in 
a carriage has succeeded in rousing- and giving- tone to the system, in the last 
stage. Friction on the limbs with the flesh brush; rubbing them with the warm 
hand, are useful: Exposure to cold air in rising-, as it sometimes has produced a 
fatal chill, should be avoided, and after the convalescence has been established, it 
may produce a relapse with local determinations. The excessive use of stimulants 
may do so likewise : a few purges in that case, with u mild diet, and bhsters to the 
seat of inflammation will generally eflect the cure.* C. 

There is a third class of symptoms which has been supposed to 
indicate the propriety of a similar plan of treatment; I mean those 
which denote irregularity in the action of the nervous power, such 
for instance as subsultus tendinum, picking of the bed-clothes, and 
a tremulous tongue. These are distinctly symptomatic of cerebral 
irritation, of a state which is indeed sometimes relieved, but not 
unfrequently aggravated, by wine and bark. If these symptoms 
are present along with a parched tongue, a hot and dry skin, and 
any degree of sharpness of the pulse, wine even in small quantity 
is generally hurtful. It is a state wdiich may often be better com- 
bated by local bleeding, blistering, and laxatives. Wine is indeed 
at most times a doubtful remedy in fever, w^hich should never be 
persevered in, unless the signs of improvement are very unequi- 
vocal. 

In these cases we will always be safe by resorting to a middle course, — by the 
use of cold water to the surface, by spunging or sprinkling, when the heat is above 
98° and if it be below, or about natural, instead of g-iving- wine, by supporting the 
strength witli decoctions of barley, tapioca, arrow root, milk and water, whey 
repeated in small and frequent doses: It is not true that the stomach will not 
digest in fever; the alvine evacuations under this plan become natural, the sub- 
sultus, picking of the bed-clothes, and dehrium disappear, and even the necessity 
of purgatives is avoided, as the evacuations become regular: If local inflammations 
be present, they are not increased: The irritabihty of the system declines as the 
patient gains strength, and the mind and nervous system recover at the same time. 
Yest in this state of the system is highly useful. With rcg-ard to the use of stimu- 
lants in typhus, it may be laid down as a principle, that they should never be given 



Thomas and Good. 



112 TREATMENT OF CONTINUED FEVER. 

when the pulse is febrile, the skin hot and dry, with local pains, the debility 
increasing- towards nig-ht with the fever: The above plan will always be found to 
be a valuable substitute, and should form the diet of typhus. The food should 
be given in moderate quantities, and often repeated. As the irritability of the 
system diminishes, to the diet may be added infusions of serpentaria, and of the 
bark: The serpentaria tea should be prepared in a stone jug- closely corked to 
prevent the escape of its aroma, which makes it sit better on the stomach. 

With regard to the use of cathartic medicines, by some they have been recom- 
mended in large and repeated doses: The practice, though supported by the 
great name of Hamilton, of Edinburgh, is too debilitating: The bowels should, it 
is true, be cleared of all unnatural collections of fcecal matter, but farther than 
this, the use of aperients should be avoided: It should be always recollected, that 
after the first depletion in the typhoid state, every further increase of the debility 
must be carefully guarded against; and that the strength is to be supported by 
nourishment of the simple and digestible character above mentioned. 

In typhus fever often the stools become black and offensive with a great increase 
of the depression and debility; in this state, the use of laxatives are particularly 
necessary: for this purpose, rhubarb, with soda, magnesia, and injections will be 
proper, with the use of the above diet, which will assist the evacuation of the 
bowels, and render the stools natural. The absorption of this foul recrementitious 
matter, produces a bad effect; by filling the blood-vessels with a poisonous and 
unnatural matter, which should not lie long in the bowels without being eva- 
cuated. C. 

2. The effects of all stimulant remedies are to be carefully 
watched. Even when most essentially required, as in the lowest 
state of collapse, they will sometimes occasion a degree of excite- 
ment, from which danger may be apprehended. If the tongue, 
under their exhibition becomes dry, and delirium increases, they 
should be immediately diminished, or altogether withdrawn. If 
the patient is upon the whole improving, this should satisfy us. 
Any attempt to accelerate his recovery by increasing the quantity 
of wine, will only risk his safety. 

From the w^ant of sleep, and restlessness which so generally 
prevail in fever, and which are so distressing to the patient, opiates 
might be expected to be useful, but experience tells us otherwise. 
In the early stages of the disease they are quite inadmissible; and 
even in the latter, their employment is often followed by an aggra- 
vation instead of a relief of the symptoms. Besides this opium 
frequently augments the heat and thirst, constipates the bowels, and 
increases delirium. In some few cases indeed, an opiate at bed 
time, as in the following form annexed is advisable; as for instance, 
when, after purging and local bleeding, great restlessness, " watch- 
fulness and starting" continues, attended with a low muttering deli- 
rium, aggravated towards night. 

H. Mist. Camph. ^i. 

Tinct. opii gtt. xxx. 

Liq. Antimon. tartar, gtt. xv. 

Syrup. Croc. 3!. 
M. ft. haust. 

If, on tlie following morning, the tongue appears dry and smooth, 
the opiate was probably injurious; if moist, it may safely be repeated. 

These remarks apply to those cases, in which there is increased action. When 
there is a tendency to a typhoid or typhus state, small doses of opium combined 



TREATMENT OV CONTINUED FEVEIl. 113 

with nitre, with the citrate of potash, or tlic spiiltiis miiulercri will excite ])cr- 
spiration, reduce the fever, and promote sleep at nij^lit. In the last stag-c of ty))hus, 
when debility prevails, opium and camphor combined are the most valuable assist- 
ants to calm and quiet the ag-itated nervous system; the camphor is valuable because 
it excites less than the opium. It may be used alone or combined with small 
doses of laudanum, when inflammatory action or local determinations forbid opium 
alone. In the old, the debilitated, and the weak, previous to their illness, it may 
be used with more propriety? when the disease also has been the result of a hig-hly 
contagious atmosphere, or when the patient has lived generously, using ardent 
liquors as a part of his daily food; these cases require a more liberal use of wine 
and other stimulants. The disease occurring in autumn, particularly after a hot 
summer, in hot climates, in low and miasmatic situations, in wet and hot seasons, 
require a more liberal use of wine. The rehef of the debility, the promotion of 
perspiration, increase of strength, all show the necessity of continuing it. 

This view of the subject is confirmed by Pringle, who states that he used them 
merely to support the strength, till nature showed a disposition to perspiration; 
there was no intention of relieving the head, or forcing a sweat by them, as he 
observed, that it was entirely in vain to bring on a crisis sooner than the fourteenth 
day: The proof that wine or other cordials are used in too great quantities, is 
seen in the wildness of the eyes, or the voice becoming- quick; tliese symi)loms 
evince the approach of frenzy, and show that the stimulants must be diminished; 
bhsters then are valuable, though before they have no good effect: fomentations 
of warm water and vinegar to the feet are also useful, and often produce in the 
delirium of these fevers, as great an effect as blisters: When the delirium is 
attended with a slow voice and without violent motions, the bark and wine should 
be g-iven, without any other medicine, waiting till the crisis takes place for the 
solution of the fever, delirium, &c. : A plan either too heating, as that by cordials 
given early; or one too cooling, as copious bleedings, increased the delirium: in 
the whole course, ^therefore, of this symptom, we must be directed by its intensity, 
withdrawing all stimuli, and substituting' depleting measures, or the conti-ai-\-, 
according- to its character.* 

Pringle also used opiates with success in the decline of fevers, when the inflam- 
matory symptoms were much abated, when there was no affection of the head, and 
when the patient, after long watching", believes he should be well enough if he 
could but sleep; care must be taken to prevent costiveness by the free exlilbition 
of laxatives or clysters, C. 

In particular states of fever, the efficacy of blisters has been long 
acknowledged, and several different explanations of the fact have 
been offered. They have been supposed to act as stimulants, or to 
have a power of relieving spasm, and they have accordingly been 
recommended by some at any period of continued fever. By others, 
they have been principally resorted to in the latter stages of the 
disease. Their good effects have been then traced to a principle of 
revulsion, and they have been chiefly applied by such practitioners 
to the calves of the lei?s, and the soles of the feet. It is now, how- 
ever, generally agreed, that blisters are only useful in obviatmg 
those local congestions and inflammations which occur in the course 
of fever, and more particularly within the head, bringing on that 
state of cerebral irritation which is marked, sometimes by delirium 
accompanied with much restlessness and attempts to get out of bed, 
and occasionally by the opposite, but no less formidable, of^ stupor. 
Under these circumstances, great benefit is experienced from the 
application of a blister to the nape of the neck; besides which the 



* Rush's Pringle, p. 278-9. 
15 



114 TREATMENT OF CONTINUED FEVER. 

head should be shaved, and cloths dipped in a cold lotion con- 
stantly applied to it. In cases of local determination to any organ 
of the thorax or abdomen, a blister over the affected part will prove 
equally advantageous. 

The propriety of blisters, as of other remedies in fever, is determined mainly by 
the pulse. In the inflammatory forms, after it has been reduced by general and 
local bleeding", blisters become advisable. They may be produced either by 
applying a decoction made by boiling for ten minutes half a pint of the spirits of 
turpentine, with half an oz. of powd. cantharides, over the part with muslin wet in 
it: It acts in half an hour, and prevents the increase of the s3^mptoms by the irrita- 
tion of the kidneys and bladder, a common effect of blisters. The skin may be 
inflamed and a blister produced by mushn wet with the volatile spirits of ammonia, 
applied in the same way — or by equal parts of nitric acid and water, cautiously 
laid on the surface, or by a fluid paste of mustard and water or vinegar, spread 
b'etween two folds of linen well wet: these modes arc speedy and therefore pre- 
ferable to ordinary blisters. 

There can, however, be no question that blisters applied to the wrists and ancles, 
and in some cases to the thighs, support life for many days, when it is nearly 
exhausted and flagging, as in the last stage of typhus: at all times when the fever 
is on the wane? when the legs are cold, these remedies will be found useful on the 
ancles and wrists. The turpentine decoction, or the common blister will be best 
from their permanent effects. 

Blisters are particularly advisable, when there are local pains, as in the head^ 
then a blister between the shoulders relieves them, after the pulse has been suffi- 
ciently reduced: a stitch in the side, or cough, is also effectually removed by 
applying the blister over it. Sydenham relieved coma with great effect by apply- 
ing it between the shoulders. C. 

In the progress of continued fever, some symptoms occasionally 
arise, which from their urgency, demand particular attention; but 
for the management of these, no specific directions can be given. 

The milder forms of continued fever are often kept up by weakness in the last 
stage; the sulphate of quinine in small doses, as a grain every two hours; or the 
infusion of bark, with some aromatic, as orange peel should be given; also columba, 
and quassia; if no untoward symptoms result, as anxiety, stricture across the breast, 
head-ache, heat of skin, febrile excitement of the pulse, they may be continued; 
The mineral acids, the muriatic, the sulphuric, and the oxy muriatic made into a plea- 
sant drink with syrup and water, are then valuable to excite an apjietite and hasten 
the convalescence. The bark may also be given in substance where the quinine 
cannot be had. It should be given in the dose of 5i eveiy two or tliree hours; if 
it purges, four or five drops of laudanum may be taken with each dose. If it 
sickens the stomach, the plan proposed by Dr. Cartwright of giving it between 
two wafers made by dropping on a hot smoothing-iron a paste made of flour, and 
putting the bark between them, wetting their edges slightly, will be found to be 
convenient. C. 

During the convalescence, the diet of the patient must be strictly 
regulated; but in the way of medicine, little else is required than an 
occasional laxative, and the exhibition of a light tonic, such as the 
infusion of cascarilla, bark, or columba. 

Gentle exercise on foot; within doors at first, afterwards in a carriage or on 
horseback; and the cold bath, with frictions with the flesh brush will assist in 
establishing the cure: Removal to a high, well ventilated, mountainous country, 
will also be useful. 



( 115 ) 



CHAPTER VI. 

TYPHUS SYNCOPALIS. 



Sj/?7iptoms — Prognosis — Caicses — Jippcarances after Death- 
Treatment. 



SYMPTOMS. 

It is necessary here to give some account of a variety of typhus which has 
appeared principally in New Eng-land, and other parts of North America.* Its dis- 
ting-uishing- feature is the sudden debility, which prostrates the system; occurring 
either in fainting, symptoms of palsy, apoplexy, hysteria, concussion of the brain, 
cholera, or general and excessive weakness; without any appearance of re-action, 
throughout the whole disease. The symptoms are excessive, rapid, and destruc- 
tive; the extremities are cold, the skin numb, insensible to the most powerful 
rubefacients and blisters: There is a feeling of great sinking at the epigastrium.-!' 



* " Ttphus-st:s-copalis may be defined, A Nervous fever^ in ichich the stage of 
re-action is wanting, the torpid or forming stage and the stage of exhaustioii being 
blended together, attended ivith pain in the head and vertigo, and paroxysms of gastric 
sinking; and for the most part, with a cool skin and slow pulse, and an absence of 
all febrile smell. Petechia, eruptions, ecchymoses, general suffusion of the 
capillaries, coma, delirium, palpitation, interrupted respiration, numbness and 
insusceptibility to the action of ordinary rubefacients and epispastics, and sinking 
after evacuations, are much more common than in any other febrile disease. By 
attending to these symptoms, it may be more easily distinguished than any other con- 
tinued fever. Coma or delirium may sometimes be so severe or so protracted, as 
to overwhelm or disguise every other symptom; or the attack may be so violent as 
to destroy hfe in a fev/ hours; and in these circumstances, in sporadic cases there 
may be, with the inexperienced, some hesitation as to the nature and name of the 
complaint; but on the whole there is less hability to mistake, than in the diagnostics 
of any other acute fever with which we are in the habit of meetiiag, in the ordinar}"- 
course of practice. Dysenter}', cholera, cynanche, catarrh, cough, pneumonia, 
measles, rheumatism, gout, and even common typhus, are often complicated with 
it; yet there is always some pron^nent sjTnptom by which it may be detennined, 
when the general affection of the system is that of typhus-syncopalis."§ 

t There are two kinds, according to Dr. Miner. The most common variety of this 
symptom, was described " sometimes as extreme distress, sometimes as a painful 
sense of vacuity and faintness, sometimes as trembling or fluttering, sometimes as 
real pain and anguish, and at others, was declared to be utterly indescribable. 
During the existence of these paroxysms, the coolness and numbness of the skin, 

t " No theory leads to move eTceptionable practice than that, which supposes sinking' typhus to be 
originally a gastric disease. This liss been the c^use of the death of hundreds, and converted hundreds 
of mild into tedious and protracted cases, and into spurious bilious fevers. Those physicians who aroid 
much vomiting or purging, and know bow to use opium etficiently in substance, or by enema, are leldom 
much troubled with vomiting, and rarely mistake it for a gastric or bilious fever." 

i Dr* Miner on Typhus Syncop. 



116 TYPHUS SYNCOPALIS. 

The stomach is either entirely insensible or excessively initable; an erect position 
exhausts the patient; the pulse is in-egiilar and varial)le, often full, when exhaus- 
tion is about to take place; evacuants debilitate, and suddenly place him beyond 

the lividness of the extremities, the feebleness of the pulse, and the indications of 
distress in the countenance, were much augmented. Sometimes, these paroxysms 
of sinking-, were attended with palpitation, and otteliwith spasms; though spasms, 
tremors, and subsultus Mere not uncommon in every stag-e. In the mild cases, these 
paroxysms of sinking occurred regularly in the morning; but in the severest, they 
were not confined to any particular hour of the day.'** 

" In many of those cases which were neg'lected, or treated with evacuants, or in 
which the early symptoms were not decisively and fully met and subdued by 
appropriate remedies, a peculiar and somewhat different, and usually irreparable 
sinking and exhaustion occurred after a critical effort, or in lieu of a crisis, on the 
third, fifth, or more commonly, on the seventh day. In a few cases, it did not 
occur till the end of the second or tliird week. Under such circumstances, in addi- 
tion to the sinking in common with other cases, the respiration was interrupted 
and peculiar, and much resembled that of the dying, or rather that of animals (as 
is described) after a division of the par vagum, the inspirations occurring only at 
intervals of several seconds, and being usually long and full, while the expirations 
were so short, that the breath was parted with instantaneously. This critical sink- 
ing, in combination with morbid respiration, was often the first warning of danger 
to the patients and attendants, in the insidious cases, and it was almost invariably 
irremediable; for, although every symptom could be met, for a time, to the full 
extent, and although the most* decided operative effects of medicine could be 
produced, and life often be prolonged for days, yet the weight of the disease could 
rarely be lessened, and, in one of the succeeding critical efforts, the same symp- 
toms would almost inevitably prove fatal. In other fatal cases, the disease termi- 
nated in a deadly coma. Paroxysms of coma were periodical in some instances, as 
were those of sinking in others. The former description of sinking and anxiety, 
which was principally referred to the epigastrium, in distinction from tlie O'itical, 
may be termed ordinary sinking. It was usually relieved when taken in season, 
and treated with energ}'.t" 

• Miner's Essay. 

+ '• ll is necessary to make further coniriient upon the two kinds of suhshlentia, or sinking', or rahnttemtnt 
as it is called by the French, as they are hut little understood, and can ntver be realized by those who 
have not witnessed this disease in its severest form. Gastric ninking is the diagnostic symptom of typlius 
syncopalis, and is common to ercry case, wliere it is not disguised by coma, delirium, or prompt treatment. 
It also belongs to Good's cardialgia-syncopalis (or syncoptica) and" is a variety of the anxiety, angvish, or 
distress, which all writers mention as belonging to the last stage of feve>. It appears at any stage in 
typhus syncopalis. (1827.) These sinkings are so common, as to be properly reckoned among the diag- 
nostics of ordinary cases. These symptoms have been (he cause of much of the applause, and much of 
the reproach, that have prevailed, conceringwhat is usually called thf stirnulnline^ practice. Tlie objec- 
tions have almost uniformly come from those who have |had little or no experience of the disease in its 
worst and most sinking varieties. In the paroxysms of orditun-y subsidentia, the patient is sure to find 
relief by an efficient use of aromatic drinks, essential oils, alcohol, ether, or opium, assisted by external 
stimulants; and in the more urgent cases, there is no othtr mode of relief. The patient must use them 
freely, or he sinks for ever. The author is confident, that no instance of recoven- from this disease, in the 
severest form, can be ))roduced under an opposite method of treatment. In the more obstinate paroxysms, 
tlie quantities of some of these articles, that arc not only borne with impunity, but that are imperatively 
demanded, are incredible to a stranger to such sinking cases. Every patient feels, and every bystander 
sees, their saluUiry effect. It is necessary to keep up this eflect by the same articles regularly and fre- 
tjiiently administered, thoug^h in much less doses tiian during the paroxysm, which may prevent its return 
in any alarming degree. In moderate cases, those fits of sinking when left to themselves, do not at first, 
destroy life, but each succeeding one reduces the vital powers so much, that a paroxysm of a-itical sink- 
ing soon supervenes, Uiat instantly jeopards life. When this critical sinking does occur, the most divided 
practice is necessary to prevent instant death; and in defiance of every exertion, in the majority of cases, 
It is believed, it finally proves fatal. Life may usually be prolonged for hours, and sometimes days and 
weeki, but the system has received such a shock, that ultimate recovery is rarely to beexi)i'cted. However, 
it is always our duty to support the patient ns long as iwssible; and we succeed often enough in producing 
a new secretion of vital power, to prove, that desperate cases should never be neglected, and at the sjime 
liiAe, to demonstrate the salutary effects of medicine in jialliating, even when it cannot remove disease. 
Those who are ignorant of the extreme malignity of the disease, in i^'eneral attribute death in those cases 
'to the medication. If a physician suffers his ))atient to tlie in one ol these paroxysms, he loses no reputa- 
tion; but if with the most exquisite skill and judgment, he prolongs life for days or weeks, and the case 
finally tails, he is almost sure of being censured for his practice. When sporadic cases of this fever first 
occur, they are generally mortal, and the patient is usually said to die of a ft of apoplexy, of angina- 
pectoris, of hydrothorax, of organic affection of the heart, or of some such fatal disease, lie does often 
die, before sufficient re-action is produced to show that he laboured under a febrile disease. No fever 
ie(juires greater nicety in adapting the treatment to the syniptoms of individual cases thau this, as some 



TYPHUS SYNCOPALIS. 117 

the power of remedy: all these symptoms sufficiently distinguish the disease from 
the ordinary typhus:* 

Tlic disease sometimes attacks suddenly, running its course in from three to 
seven days; sometimes it is more insidious, not assuming" an alarming character till 
the seventh day : 

Dr. Gallup describes the disease as often attacking with local pain in some part 
of the system, back, side, &.c. shifting from one part to another; sometimes a small 
portion of the surface is excessively cold and numb: Lassitude attacks the muscu- 
lar system, followed afterwards by soreness in the flesh: Petechi?e resembling flea- 
bites often occur; they appear of the size of a pin's head, in great numbers and m 
patches, giving the skin a dusky appearance and a forbidding aspect. f 

Frequently the eruption resembles the' measles, at other times it is vesicular; 
sometimes the vesicles are few, large, and the blisters contain an ichorous matter. 

They are uncertain in their duration; the slight and partial ones soon disappear- 
ing: If they turn to a bright red the case is favourable: The eruption in the epi- 
demic described by Dr. Gallup, occurred in about one in six cases; and did not 
appear to be an essential symptom of the disease; though it was named from it. 

The same malady as it occurred in Philadelphia, I have seen sometimes, though 
rarely, attended with petechia. 

According to Dr. Gallup, though he saw the disease often united with cholera 
and dysentery, the other viscera of the abdomen were rarely affected. 

The countenance is generally placid, with often a flush upon the cheek: as the 
disease advances the countenance falls, the features are changed, become bloat- 
ed, are of a dark sublivid hue, with deep brown patches and red eyes. 

Great mobility awd changeableness of symptoms characterize the disease; com- 
mencing generally with a pain in the forehead, between the eyes, with vertigo, 
with extreme lassitude, sinking and desire for rest, faintness, and sinking at the 
stomach, sometimes with cliills, often without; it assumes in its other stages, like 
other epidemics, all the variety of affections which afflict the human body, and is 
generally to be distinguished by the prostration which characterizes all its forms; 
re-action seldom or never taking place after the disease commences. 

Sore throat sometimes attends this fever, often not mentioned, however, without 
the attention is called to it. 

Dr. North states that a great and surprising loss of strength, is a constant and 
prominent symptom of this disease; also violent pain in the head; the pulse is 
extremely variable, but always weak; it intermits, is fluttering or totally absent, 
is covered with a white coat, and in some biUous cases is of a brownish hue: Often 
the disease terminates by hemorrhagies from different parts of the system, t 

* See Miner on Typhus Syncopahs, p. 19. 1825. 

t Gallup on Spotted Fever, p. 233. 

t The following case by Dr. Thomas Miner, will give an adequate idea of the 
danger of this malady. 

" Sunday, January 28, 1816, one o'clock, P. M. I was called to visit, in consulta- 
tion, J. N. Y. aged seventeen years. The first sight of the patient struck every 
beholder with horror. He was as stupid as a block, unconscious of any impression 

of them are vei-y slight, and require only moderate practice. The charge of indiscriminate practice is 
utterly groundless, and the general Inference that is attempted to be drawn from paiticular cases, is 
entirely unwarranted. From a conversation of a few minutes with any intelligent physician, it is easy 
to ascertain, whether he has ever witnessed the whole progress of a very malignant epidemic. If he has 
not, or has only superficially viewed sporadic cases, or if he has only seen the disease in its mildest form, 
or in the intervals of the paroxysms of sinking, all his analogies will fail him. How a patient can sink 
irretrievably, sometimes on the first day of his disease, from a single emetic, cathartic, venesection, or 
enema, or even a draught of cold water, when at the same time, he might probably have been restored 
under proper treatment, is utterly incomprehensible, to most of such as have not repeatedly witnessed 
their effects. And on the other hand, it is equally mysterious, how doses of medicine, that in ordinary 
cases might endanger life, may be given with the utmost safetv, and the most prominent advantage. It 
is equally incredible, that some cases may be trusted a week without the I)owels being moved, and not 
only so, but that the slightest eccoprotic, if it could be made to operate, might destroy life. The fact that 
coma and other typhoid affections of the brain, are more surely relieved by opium than any other remedy, is 
equally incomprehensible. How ever, no facts in medicine are better kiiown by the truly experienced, or 
are supported by more substantial testimony. The insusceptibility to the action of medicine in ordinary 
doses, in sinking typhus, compares with the same state in cholera of India and tetanus more than in 
ordinary fevers. In delirium tremens, a patient of professor B. of B. in one night, took a pound and a 
half of tincture of opium, and recovered:!! The author states this from very accurate informatioD."i5 
§ Miner's Essay. 



118 TYPHUS SYNCOPALIS. 



PROGNOSIS. 



The degree of the violence of the symptoms generally determines the proba- 
bility of dan g-er: and if they be violent, yet, on exhibiting- the medicine are easily 
controlled, there is little dang-er: Difficulty in swallowing-, excessive irritability of 



on either of the senses, and so convulsed, that it required three or four men to 
hold him on his bed. His eyes were open, and rolled back, so far as to hide the 
coloured part, and his teeth were as firmly clenched, as in locked-jaw. His face, 
arms, leg's, and body, were Uterally covered witli spots, somewhat resembhng", in 
appearance and colour, gunpowder shot into the skin; though in several places, 
they run together in patches, from the size of a cent, to that of the palm of the 
hand. The coldness of death pervaded the whole body, except the parts which 
had been warmed by external heat, and there was no pulse in either wrist. The 
convulsions, though they continued most of the time, would occasionally remit, so 
that there was, now and then, a slight relaxation of the jaws, sufficient to introduce 
the end of a spoon; and though he remained insensible, after his throat had been 
irritated, a few seconds, by some liquid, he generally swallowed the greater part 
of it. During these relaxations, he parted with his faeces profusely, and lay 
drenched in accumulated filth. 

The previous history is as follows. 

The patient, an apprentice to a smith, had been employed the Friday before, 
in a very warm shop, assisting in tempering sword blades. On Saturday morning, 
the weather being extremely cold, he \vent a mile from home, and was much 
chilled; but on his return, performed his usual labour in the shop, till near night. 
Towards sunset, he complained of severe pain in the head, sore throat, loss of 
strength, coldness, and that indescribable anxiety, which the sick term distress, in 
distinction from acute pain. His sister, v/ho was his nurse, very properly adminis- 
tered an infusion of some aromatic herb, sent him to bed, and applied external 
heat, till free perspiration was produced. He seemed much relieved in the evening, 
and about ten o'clock, went to sleep. A man was left with him, to watch his 
symptoms, and furnish him with drink. He slept tolerably well, and nothing pecu- 
liar was remarked, except when he awoke in the night, he was thirsty, and drank, 
it seems, freely of cold drink. About four or five o'clock in the morning, he was 
found to articulate with difficulty and incoherence, and delirium was soon per- 
ceived. The spots were now discovered. A physician was called, who came 
about seven o'clock. An antimonial emetic was administered, which operated 
two or three times slightly, and soon produced the catharsis, under which he was 
still labouring, when 1 first saw him. Little else appears to have been done, except 
the application of a blister to the region of the stomach, with frictions, fomenta- 
tions, external heat to the limbs and body, and occasional!}^, administering warm 
aromatic drinks. 

Thougli the case appeared to be hopeless, I advised the use of laudanum, and 
brandy and water, and remained with him about an hour and a half, to watch their 
effects. During this time, the diarrhoea was checked, and a weak pulsation 
returned to the wrists. Being now obliged to leave the patient, I can only state, 
that he is said to have had no peculiar change of symptoms; but he became more 
and more exhausted, and died at one o'clock in the night, after an illness of about 
thirty -two hours.'* 

REMARKS. 

"I could mention another, that I witnessed, a few days afterwards, which proved 
fatal, in an hour and a half, after there was sufficient alarm to call a physician, and 
within six hours from the first ap])arcnt indisposition. No medicine, except 
twenty-five minims of laudanum, and warm mint tea, was attempted to be adminis- 
tered. The skin had a marbled, motley appearance, but no petechiae. I saw a 
third, the same season, who died in eighteen hours. He had no spots. These cases 
were so palpable, and so little medication was employed, that no one suggested 



TYPHUS SYNCOPALIS. 119 

the stomach, a coldness of the suiface not to be overcome, great insensibility, 
coma, difficult respiration, are fatal symptoms. 

Petechiae, vibices, are always dangerous, but particularly in proportion to the 
darkness of their colour: Dr. North considers that dark coloured petechiae, obsti- 
nate vomiting*, a cold surface, little or no pulse, rigidity of the limbs, appearing- in 
a few hours after the attack are dangerous: In many cases, after the patient was 
believed to be beyond all hopes, the symptoms of recovery took place. Dr. Gallup 
confirms the dangerous character of coma and petechiae. 

CAUSES. 

These are the prevalence of cold and moisture; the debilitating passions; sis 
grief, fear, fatigue, excessive stimulation; debility produced by other diseases; 
Cold is, however, the most frequent exciting cause.* 

APPEARANCES AFTER DEATH. 

The petechia semetimes cover the whole body, and diminish in the more pro- 
minent parts after death. The muscles exhibit a deeper shade than natural; the 
blood-vessels of the brain, more especially the veins, are very turgid: The brain 
exhibits signs of inflammation throughout its whole texture, adhesions between 
the brain and the dura mater, and also between the dura mater and the cranium: 
an increase of serous secretion, and also pus are found in tlie different parts of the 
cavity: and the veins are particularly turgid. Marks of inflammation also exist 
throughout the thorax. 

TREATMENT. 

The treatment according to Dr. Miner, is founded upon one general principle; 
everything which wastes the vital powers must be avoided: Purging and vomiting 
generally exhausted the system, and were almost always fatal: Opium is the main 
stay in the treatment of this malady: It should be given with the purgatives, as 
two or three operations often debiUtate the patient beyond recovery. 

that they were killed by the stimulating practice. Many others, to appearance, 
equally severe with the first case, could be stated, wliich were cured by a timely 
recourse to proper treatment. 

_ Spotted-fever appears to have its seat and throne in the brain, to belong nosolo- 
gically to the passive phlegmasise. It is attended with no spontaneous re-action, 
but has the forming and supporting stages blended together. This is manifest, by 
the gi-eatest arterial debility, typhoid delirium and convulsions, paroxysms of sub- 
sidentia, and in a word, by every symptom, which is known to indicate an extreme 
deficiency or exhaustion of the powers of life. 

By an energetic, exciting treatment, at its access, this disease is frequently 
broken up, within twenty-four hours. When we fail in producing a resolution, and 
only make such an impression as to moderate the violence of the symptoms, it 
usually continues seven, or in some instances, fourteen days, requiring the same 
course of practice, according to the urgency of the symptoms, as is demanded in 
the supporting stage of typhus. 

One circumstance should be noted. Though the body, when coldness prevails, 
should be warmed by external heat, fomentations, vapour, or warm-bath, and it is 
desirable to produce and keep up a moderate diaphoresis, yet there is much hazard 
from excessive sweating. Indeed, it is not a rare occurrence, to find morbid 
sweating, through the ivkole course of any low, typhoid fever. The great difficulty 
in treating successfully such rapid diseases is, that the physician, too often, is not 
called till so late an hour, tliat he finds all the powers of life exhausted, and the 
patient already in the agonies of death, "f 

* North, 1811, p. 27. 

t Dr. Miner. 



120 TYPHUS SYNCOPALIS. 

Dr. Miner found tliat calomel joined with a diaphoretic medicine, if it did not 
operate for twelve hours, cured the patient effectually: Two stools, however, often 
detroyed the patient from the excessive debility they produced. 

Often the bowels in this disease are not opened for a week, and without incon- 
venience to the patient: Tenderness, uneasiness, or slight pain in the abdomen, 
are the s} mptoms which indicate that the bowels should be moved, and for this 
purpose, the mildest laxatives are pro])er: Small doses of magnesia or enemata are 
recommended for this puri:)0se4 the ojiium in the mean time must be continued to 
support the system, as this last is the main and principal indication throughout the 
disease; salivation was of no use. 

The quantity of opium given by Dr. Miner was 3 or 4 grs. in an hour, or half a 
drachm and even a drachm in substance in the course of twelve hours. This applies 
to the epidemic of 1'823; there was, however, a mild variety which required only 
the use of a negative treatment, and to refrain from the use of hazardous or uncer- 
tain remedies.* He states that all who took opium invariably recovered. A soft 
and frequent pulse, with general weakness, renders necessary the exhibition of 
stimuli, of which wine, if the case be not violent, will be the most proper: It may 
be given sweetened with sugar, by the tea spoonful, and will lie upon the stomach 
Avhen nothing else will: The quantity which can be taken in this way, is often 
enormous; as much as a pint has been given in the space of an hour with tlie 
greatest possible benefit. It may be given warm. 

As much as four bottles of claret have been given in twenty-four hours with tlie 
most decided advantage: Dr. Bestor, we are told by Dr. North, gave two quarts 
of brandy and one quart of wine in twenty-four hours, and also twenty drops of the 
tincture of opium every two hours; I have seen the same quantity of brandy taken 
by a delicate woman in the space of twenty-four hours in this disease; the only rule 
necessary to be observed in regulating it, is not to intoxicate, but to keep up a 
continued stimulation, without regard to the quantity: The usefulness, however, 
of these excessive stimuli apply only to the sinking and exhausted state of the 
system, which, if not supported, soon ends in death: More permanent stimuli, as 

* "In the mildest cases, after cautious purging with calomel, the prescriptions were 
almost negative; such as, to avoid vegetable acids, cold water, muscular exertion, 
an erect position for any considerable length of time, much purging, and various 
other hurtful measures. [Whatever increases the peristaltic motion of the bowels, 
produces an evident tendency to sinking;, even before the evacuation takes place; 
and some of the worst ])aroxysms oi' subsidc?ilia ever met with, have occurred dur- 
ing the operation of the mildest cathartics, and even from a single enema. However, 
in the mild cases, moderate purging is proper. (1827.)] Numbers of cases might 
be stated, in which the patients, while labouring under an ap]):u'ently moderate 
disease, from a false idea that they should gain strength by sitting up, have pro- 
duced the most dangerous paroxysms of vertigo and sinking, some of which have 
been followed by death. Many of the severest cases did not admit of being moved 
from their lieds for several days; since tlie slightest motion, or change of position, 
was liable to produce a severe paroxysm of sinking, and increase the exhaustion to 
such a degree, as to require liours to regain the ordinary strength. Some slight 
cases mi^ht be trusted to aromatic, bitter infusions, alone; others, to camphor and 
ammonia. In several of these, no calomel, or opium, or alcohol, or any active 
medicine, was needed or employed, ])rovided all hurtful measures were studiously 
avoided. In many, a blister to the forehead, scrpentaria, camphor and lunmonia, 
compound tincture of cinchona, and opium in very small quantities, were all that 
were retpiired." 

** I'rofuse sweating from external heat was useless in the mild, and inefficient or 
injurious in the worst form of the disease, unless employed at the very access; and, 
in this stage, it could rarely be used with convenience. JL>y the time a ])hysician 
is called, it is generally too late lor sweating to be of mucli service; though, when 
employed very early in cases of nuddtn ii(/(u-/,; it is sometimes cajiable of breaking 
up the disease, especially in the tojpid variety. Under sucIj circumstances, i( 
ought generally to be tiled. 'I'he duration, :.cverity, and niorlallly of thlsiUscasc, 
depend ihorc than any other, ujjou the eaily management. *'[ 

I l»r. Mimr\ Kh.si.v. 



TYPHUS SYNCOPALIS. 121 

diet, Boups, sago, &c. must generally be depended upon, and as the system rises 
must he substituted 5 otherwise if brandy, opium, &ic. be alone relied on, the patient 
certainly sinks. 

So great and rapid was the sinking that the most prompt and energetic means 
were necessary: Alcohol, capsicum, were serviceable? wine, bark, camphor, 
ammonia, were too mild to be useful in the severe cases: Fowler's solution ^tas 
valuable when the head was much affected. 

Of the external applications, hot bricks; heated wood; wood boiled in water; 
bottles filled with hot water; mustard; liquor ammonix; hot steam thrown into the 
bed; frictions with ardent spirits; capsicum; and oil of turpentine, were important 
agents: It was necessary to excite the skin by applying them previously to blisters; 
otherwise the latter had no effect. 

Blisters were more particularly useful when applied to the vertex, forehead, 
temples, spine, epigastrium and extremities: to the head they were particularly 
valuable: and so decidedly beneficial were they, that the patients often asked for 
their repetition: applied near the bladder they relieved the torpor of that viscus 
so often attendant upon this malady: hot turpentine confined on the parts was very 
valuable: In a word, opium, alcohol, arsenic, aromatics, and external stimulants, 
comprehend the general outline of the treatment of this dangerous disease. 

With regard to the propriety of sudorifics, in the sinking stage it was dangerous 
to excite a copious perspiration; the excitement and support of the system was 
the only judicious plan: but as soon as the strength was somewhat established, a 
slight perspiration had a good effect; and to support it, calomel in minute doses, 
opium, camphor, and ipecacuanha in combination were recommended, by Dr. 
Fjske; he used, however, at the same time, tonics to support the system when 
petechiae were present. 

So gi-eat is the tendency towards incurable sinking and weakness in this disease, 
that sitting up, the shghtest motion or exercise, aggravated the symptoms; and 
confinement to bed, v/hen the cases were slight, with small doses of calomel, 
serpentaria, columba, bark and wine were sufficient for their cure; and at the same 
time cold drinks, as water, vegetable acids, it was necessary to avoid. Fresh air, 
liquid nutritious diet, as arrow root, tapioco, sago, gruel, barley water, chicken 
soup, wine whey are proper. The mind must be kept perfectly easy and tranquil; 
encouraged and invigorated by the prospect of recovery, and the concealment of 
the danger of the case. The Peruvian bark in the form of decoction, infusion or 
tincture; fermented liquors, as porter, beer, cider, claret, port wine, and madeira, 
in the mild cases, answered well; they should be assisted by sulphuric, muriatic, 
and the oxymuriatic acids, given in the drinks in doses, sufficient to gently acidu- 
late them. 

A decoction of the twigs of the hemlock tree (Pinus Canadensis) has been 
highly recommended by Dr. North. It contains tannin, and turpentine; the latter 
as a cordial and stimulant has considerable power. 

In the violent cases, when an active plan was pursued the patient got well in 
from three to seven days; when the practice was timid, and feeble, the patient 
lingered on for fourteen or twenty. 

This disease appears to be more properly peculiar to winter and to cold climates: 
In Pennsylvania it occurred in the years 1813-14, and required the energetic plan 
just described, in tJie sinking cases: It however had analogies with the common 
typhous fevers, and requii'ed, in some cases, the use of purgatives to discharge the 
stools, which were black; they, then, were followed by immediate recover)-: In all 
the Simulating plan was necessary; and it was the principal reliance in the treat- 
ment; venesection was fatal. It appears, indeed, in the violent cases to resemble 
exactly the cholera of India, and to require the most decided and active 
stimulation. 

When the disease occurred in the form of mania, or delirium, it was generally 
curable; Hot applications to the legs, with warm aromatic teas, opium, camphor, 
wine, or ardent spirits, given in quantities sufficient to ease pain and support the 
pulse were found necessary,* particularly when it occurred in the cold stage. 



' North, p. SL 
16 



123 TYPHUS SYNCOPALIS. 

When it happened in the hot stage, it was less dangerous and was treated by cold 
applications to the head. A blister to the neck was uniformly successful.* 

When obstinate vomiting occurred, opium; camphor in a sohd form; bladders of 
wann water; blisters to the stomach, wine and other cordials, should be given: 
When the system is febrile, the use of the neutral mixture of salt of tartar and 
lime JLuce; the spiritus mindereri; seltzer water, creta ppt. rendered aromatic 
with a httle powdered cardamom seeds, and followed by a little diluted aromatic 
sulphuric acid made sufficiently warm, are recommended by Dr. North as being 
valuable. 

The Fowler's solution also controls this symptom very effectuaUy, 

When it occurred in the form of cohc. Dr. Bestor found that a blister over the 
belly, and an injection of three gills of yest, and a glass of brandy, followed after- 
wards by some laxative administered in the same way, was valuable: Purgatives 
were followed by death, from the debihty they produced. 

Strangury was relieved by the warm bath, when the system was above par; if 
cold and torpid, then stimuU should be given; of tliese, tui'pentine, and brandy, 
will be found useful. f 



* North, p. 53; and Dr. Miner's Essay on Typhus Syncopalis, for many excellent 
observations on this interesting subject. 

f See Dr. Woodward's account of this disease as it appeared in Berlin, (Conn.,) 
in N. Eng. Med. Rev. for 1827, for many interesting facts on this subject. 



( 123 ) 



CHAPTER VI. 



OF THE PLAGUE. 



Its nosological Character — Origin and History — Symptoms of 
the Plague — Mild Form of Plague — Effects of different 
Remedies — Of the Contagion of Plague — Its peculiarities — 
Circumstances tending to render the Plague epidemic. 



ITS NOSOLOGICAL CHARACTER. 

The Plague, classed by Dr. Cullen among the exanthemata, is 
yet, in strict nosological language, a continued fever closely allied 
to typhus, and therefore demanding notice more particularly in 
this place. It may be viewed, indeed, without over-refinement, 
as the link which connects the two great classes of idiopathic fevers. 
In its mode of propagation, it resembles the exanthemata. In its 
symptoms and progress, we shall trace an obvious resemblance to 
those of typhus. 

ORIGIN AND HISTORY* 

The historical details connected with this very singular disease 
are highly interesting. The ancients do not appear to have been 
acquainted with it, but it must be confessed that its origin and 
early history are involved in much obscurity. For many centuries 
past it has been endemic on the shores of the Mediterranean; and 
though it has occasionally shown itself in other latitudes, as at 
Moscow in 1771, and in this country in 1665, yet in that situation 
only is it at all times to be met with. Grand Cairo may be con- 
sidered as the great nidus of the contagion of plague, and from 
this point, at particular seasons, it spreads with a malignity scarcely 
to be estimated. The interest with which such a disease must at 
all times be viewed, has been much heightened of late years from 
the circumstance of its having appeared in our own settlements 
(in 1813 at Malta, in 1816 in the Ionian Islands,) and been sub- 
jected there, as well as in Egypt in 1800, to the observations of 



124 OF THE PLAGUE. 

our countrymen. The symptoms of the disease, the peculiarities 
in the laws of the contagion of the plague, the circumstances which 
appear to favour its diffusion, and the consequent appearance of the 
disease as an epidemic, are the points to which my attention will 
in this chapter be principally directed. 

SYMPTOMS OF THE PLAGUE. 

A feeling of great languor and lassitude ushers in the attack of 
plague, w4iich for the most part happens toward evening. There 
is always a cold stage, though it is seldom of long duration. Heat 
of skin, head-ache and giddiness succeed. The pain of the head 
is referred to the temples and eyebrows. They appear heavy, 
dull, and muddy. The expression of countenance changes in a 
remarkable manner. Sometimes there is a wild and furious look; 
sometimes a look claiming commisseration, w^ith a sunk eye and 
contracted feature. The most striking of all the early symptoms of 
plague is the staggeriiig, and the sudden extreme prostration of 
strength. A strong tendency to void the urine is generally noticed. 
The stomach is very irritable, and rejects almost every thing pre- 
sented to it. The tongue is w^hite and moist. The bowels are 
sometimes torpid, and at other times loose, the evacuations being 
always highly offensive. The speech faulters. The pulse is at 
first small, hard, and quick; but after the appearance of buboes it 
often becomes fuller and softer. It is sometimes intermittent. In 
point of frequency, its average may be stated at 100. The heat 
of skin is seldom very intense. The head is occasionally perfectly 
clear and collected. At other times, stupor occurs immediately 
after the formation of the hot fit. Some cases of the disease are 
ushered in by a violent fit of mania. The greatest indifference 
with regard to recovery prevails, and is always reckoned a most 
unfavourable symptom. 

After one, two, or at furthest three days, pains in the groins and 
axillae announce the formation of buboes. These pains are often 
highly acute, and unless speedily followed by the swelling of the 
gland, the patient dies delirious. In women the axillae, in men 
the groins are cliiedy affected.* Carbuncles appear at the same 
time, but indifferently on all })arts of tlie body. Petechia} and 
vibices are much more frequent than carbuncles, which it appears 
do not occur above once in twenty cases. The fatal termination is 
sometimes preceded by violent haimorrhagcs from the mouth, nose, 
or intestines. 

The duration of the disease is veiy various. A few cases are on 



• 'I'liis dctuil of tlic symptoms of i'lague is ubslracted, by j)crmission of Sir 
J. MacL,^rig-()r, from the ollicial reports of the ej)i(leniic of 1S16, transmitted to the 
Army Mcdicul lioard by the ollicers in charge of the Tlaijnc Hospitals in the Ionian. 
Islandij. 



OF THE PLAGUE. 125 

record, where the patient died within a few hours from the inva- 
sion. To many it proves fatal during the first paroxysm or period, 
which includes the time from the evening of the attack to the 
close of the following night. The third and fifth days are, how- 
ever, upon the w^hole, those of the greatest danger. The former 
is the usual period of the appearance of hubo; the latter, of the 
abatement of the febrile symptoms. If the patient survives the 
fifth day, and the bubo is fully formed, he may be considered as 
nearly out of danger. The convalescence indeed is always very 
tedious, from the extreme debility which the disease leaves; and 
the patient's life is not unfrequently again put into imminent hazard 
from the occurrence of gangrene in the extremities. 

Such is the train of symptoms which characterizes this disease- 
To form some idea of the extent of the mortality which it occa- 
sions, I may mention, that out of 700 persons attacked by it in the 
district of Leftimo in Corfu in 1815, seventy only were saved, 
and 630 died. It is curious, however, to observe, that occasionally 
this very formidable disease assumes a totally different character. 
The viild form of plague is not peculiar to any families, or classes 
of persons, or districts, or periods of the epidemic. It is more 
commonly met with towards its decline, but it is observed occa- 
sionally even from the very first. Buboes form in this variety of 
the disease about the usual period, generally with a good deal of 
inflammation, and go on to suppuration. Carbuncles and petechias, 
however, are never observed to attend it. It is marked by the 
same set of febrile symptoms as characterize the malignant form 
of the disease, but they are all milder in degree. It terminates 
occasionally by a critical discharge, but does not appear to require, 
or to be at all effected by, any kind of medical treatment. A few 
cases have been recorded of plague appearing in the form of buboes, 
without any constitutional affection. 

A circumstance of some importance, as tending to point out the 
analo_gy between the plague and other forms of continued fever, 
has been taken notice of by Sir James M'Grigor, in his Medical 
Sketches of the expedition from India to Egypt: — I mean the effect 
of season, ventilation, and peculiarities of soil, in modifying the 
character of the symptoms. The case's of plague which occurred 
in the cold months of the year, were marked by an inflammatory 
diathesis. Those which were sent in from crowded hospitals, 
were attended from the very first with low or malignant symptoms. 
Those which occurred when the army was encamped near the 
marshes of El-Hammed, showed a kind of remittent or intermittent 
type.* 



* Subjects who have inhabited a cold latitude and have never been accustomed 
to the debilitating influence of heat especially accompanied by the operation of 
atmospherical infection, sulTer a more inflammatory degree of plague, and all tlie 
other diseases of tropical climates. The excitability of such bodies seem to be 



126 OP THE PLAGUE. 

Some dissections have been made of the bodies of persons who 
have died of the plague, but they afford little or no instruction. 
The few morbid appearances noticed, were met with in the cavity 
of the abdomen. 



EFFECTS OF DIFFERENT REMEDIES. 

In the malignant form of plague, every variety of treatment has 
been tried, but with so little effect, that it may be considered as a 
disease nearly beyond the reach of medicine. The violent head- 
ache which occurs during the first twenty-four hours, seems to 
point out the propriety of blood-letting, and it is recommended by 
the general custom of Turkish practitioners; but in the hands of 
English surgeons it proved of no avail. In the cases in which it 
was tried it did not appear, however, to make matters worse. The 
blood first drawn was generally sizy, but never afterwards. 

Where mercury can be brought to affect the mouth, it appears to 
be of some service, but it is seldom that sufficient time is afforded 
for the specific effect of the remedy. Ether and laudanum are 
valuable medicines in allaying the irritability of the stomach. 
Wine and opium are of no use during the violence of the disease, 
and bark can seldom be retained. This is much to be regretted, 
for wherever it can be made to stay on the stomach, even in those 
severe cases where carbuncles and vibices appear, its good effects 
are conspicuous. Camphor, bark, and wine are given with much 
advantage during the period of convalescence. Emetics, purga- 
tives, and the cold affusion have been tried, but it does not appear 
that they are of any particular service. Diaphoresis can seldom 
be produced, owing to the disposition to vomit; but wherever it 
can be procured, the symptoms seem to be mitigated by it. 

Great attention is always paid to the local treatment of the 
buboes. They seldom go back, and it is usual, therefore, to em- 
ploy means with the view of accelerating their suppuration. For 
this purpose the Turks arc in the habit of applying the actual cau- 
tery, but it did not answer in the practice of our army surgeons. 
The irritation occasioned by it was excessive, so as sometimes to 
hasten the patient's death. Blisters and poultices are certainly 
preferable; but upon the whole, it is quite obvious, that as little 
can be done in the way of surgical treatment in the plague, as by 
internal medicines. 



accumulated: hence in the United States wc find many persons wlio have experi- 
enced several attacks of yellow lever. The intervention of a cold winter enaces 
the impression of the cause eng-cndcrcd in sununcr: hence we never become per- 
fectly constitutionally acclimated like the inhabitants of uniformly warm latitudes. 
All causes that occasion a chronic dc-bifily and thus impair the general nervous 
energy, i)rcpare the body for a feebler action of tlic heart. V. 



OF THE PLAGUE. 127 



OP THE CONTAGION OF THE PLAGUE. 

The general resemblance which plague bears to those malignant 
forms of typhus fever, which are occasionally witnessed in cold 
countries, must be abundantly obvious. The great distinction 
between them lies in the occurrence of buboes; in other words, in 
the tendency which plague has to affect the lymphatic system. 
This line of distinction however is so broad, that plague is to be 
viewed as a continued fever, allied indeed to typhus, but differing 
from it in the important circumstance of having its origin in 
specific contagion. That the plague is a highly contagious disease 
cannot for a moment be made a matter of dispute; but some phy- 
sicians have maintained, that it is not a fever sui generis, generated 
by a specific contagion, but only an aggravated form of typhus; in 
support of which opinion it has been argued, that cases of typhus 
complicated with buboes have sometimes been observed in this 
country.* This idea, however, is entertained only by a few, and 
the doctrine of a specific contagion in plague, is that which is now 
generally received. Its laws have been investigated with some 
accuracy, and the following seem to be the most important of those 
which have hitherto been ascertained. 

1. The latent period of the contagion of plague, or that between 
communication with an affected individual, and the appearance of 
symptoms, varies in different cases. It is scarcely ever less than 
three days, and it seldom exceeds six. Instances indeed are re- 
corded of the disease not appearing until the tenth day, but these 
cases are rare. 

2. The contagion spreads to a very small distance only from the 
body of the patient. The consequence of which is, that the 
disease is seldom, if ever communicated except by actual contact. 

3. The dead body does not communicate the disease so readily 
as the living. This appears to be well understood in Turkey: but 
that the contagion is sometimes received from the dead body, can- 
not, I apprehend, be doubted. 

4. The contagion of plague is readily imparted to fomites, in 
which it may lurk for a very long time, more particularly if 
secluded from the air. 

5. Re-infection is occasionally observed, but, upon the whole, 
is not common. The individuals throughout Turkey, who are 
employed about the persons of plague patients, have, with very 
few exceptions, undergone the disease. Sufficient instances, how- 
ever, are met with of persons taking the disease a second time, 
and even dying of the second attack, to make all who have pre- 
viously had it, cautious in their intercourse with the affected. 



* See Minutes of Evidence taken before the House of Commons on the Ques- 
tion of Plague. 1819. 



3 28 OF THE PLAGUE. 

6. Plague, like the small-pox, may be taken by inoculation. The 
experiment has been tried in several instances, but in none has it 
succeeded in mitigating the disorder. Dr. Wliyte in 1801, and 
Mr. Van Rosenfeldt in 1817, paid with their lives the forfeit of 
their temerity. The former died on the fourth, the latter on the 
second day of the disease. 

Plague I have stated to be endemic in Egypt; and both at Cairo 
and Constantinople cases of the disease are almost always to be 
met with. In other words, they occur sporadically in those places. 
While the English army were in Egypt in 1801, cases of plague 
were continually occurring; but the judicious regulations which 
were adopted, prevented the disease from spreading, and the troops 
suffered but very little from it. At Malta however in 1813, and 
in the Ionian Islands during the years 1815-16, the plague raged 
epidemically; and from very early times it has been observed, that 
at particular seasons the plague disseminates itself with extraordi- 
nary malignity. To this nothing can give any effectual check but 
the enforcement of severe measures by the strong arm of military 
power. At Marseilles in 1720, at Messina in 1743, at Grand 
Cairo in 1759, and on various other occasions, when the plague was 
suffered to advance without any such control, the ravages w^hich it 
committed were of incalculable magnitude. The establishment of 
a cordon around the whole of the affected district, the rigid seclu- 
sion of families, the immediate removal of all suspected cases into 
quarantine, and of all decided cases to the lazaret, are the preven- 
tive measures of most obvious importance. By these, promptly 
and vigorously exerted, the extension of the plague in the Ionian 
Islands has been several times, in the course of the last five or six 
years, prevented; and it is now no longer questionable, that it 
might in the same manner be eJQfectually checked in every part of 
the Turkish Empire. 

CIRCUMSTANCES TENDING TO RENDER THE PLAGUE EPIDEMIC. 

Many inquiries have been instituted with the view of determin- 
ing, if possible, what the circumstances are which render the plague 
epidemic at certain seasons. Some particular constitution of the 
air is generally supposed to occasion it; but what that is, never hns 
been, and probably never will be ascertained. The extremes both 
of heat and cold arc said to be unfavourable to the propagation of 
plague, but this opinion must be taken with some limitations. The 
plague raged in summer at Malta, in the winter months at Corfu. 
Nor is it clear, that it is upon any peculiar state of dryness or mois- 
ture in the atmosphere that the plicnomenon depends; thougli 
indeed there is a popular belief all over the Levant, that the heavy 
dews which bet»;in to fall about St. .John's day check the advance 
of the i)laguc. To this circumstance is attributed the curious but 
well ascertained fact, that though tjic disease had been previously 



OP THE PLAGUE. 129 

raging in the town, the inhabitants may after that day leave their 
bonnes and mix in society with comparative security. 

It is a common remark in the Levant, that the advances of tlie 
plague are always from South to North. When the plague is at 
Smyrna, the inhabitants of Aleppo handle goods without any pre- 
caution, and have no fears of contagion. When the disease, on the 
other hand, is at Damascus, great precautions are observed, and all 
the Frank families hold themselves in readiness to shut tip, or to 
leave the town. An epidemic plague, therefore, nearly always 
begins at Grand Cairo, spreads to Alexandria, and from thence 
through Syria to Smyrna and Constantinople. 

The seeds of the plague being always present in Turkey, if it 
were not for these peculiarities in the laws of its contagion, that 
country must have been long since depopulated. Whether the 
genuine Levant plague could spread in this climate, is a point upon 
which physicians are not agreed. The general opinion is, that it 
might so spread under particular circumstances; and therefore, that 
the quarantine regulations established by the Legislature are abso- 
lutely necessary for the protection of these countries. 

1. The plag-ue is a fever wliich owes some of its terrors to the timidity and 
ignorance of physicians: The author says that out of 700, 630 died, in Corfu: 
Sydenham tells us, that out of a number of persons, in the plag"ue, who were bled 
almost to fainting-, in Somersetshire, not one died. 

2. Like other remittents, it personates all diseases. 

3. Like the common summer fevers, it is not contag-ious; like them, it beg-ins, 
increases, and declines with the summer, the season of putrefaction: Sydenham 
confirms this statement; so does De iSIertens: like these fevers, also, it is arrested 
by frost, by removing- their cause — animal and vegetable decomposition. 

4. Any other cause, which stops this process, will also suppress the plag-ue; 
thus, the season of the dry winds from the desert arrests this disease in Asia Minor, 
because they prevent putrefaction by their want of moisture. Other reasons prove 
it not to be contagious. 

5. The houses in Turkey, as those in London were before the introduction of 
manufactures, are filthy and miserable: Erasmus tells us, that the houses of the 
poor, in England, about the time of the plague, were mean hovels, with ground 
floors, covered with rushes; the receptacles of the refuse of their meals, of beer, 
meat, &c. and of the excrements of dogs and cats; they remained there for years, 
till a hot season took place, when the putrefaction of this colluvies spread far and 
wide the poison of this fatal disease. De Mertens describes the hovels of the 
poor, in Moscow, among whom it principally raged, as being of one story, with a 
ground floor, in which they lived in great numbers, very much crowded together: 
he also states, that only three of the nobility, a few of the principal citizens, and 
three hundred foreigners of the common class fell victims to it; tlie great mass of 
the sick, who lived in these wretched hovels, were of the lowest order; of whom 
from eight to twelve hundred died every day from the first to the fifteenth of 
September, when there were but 150,000 people in the city; from this, an esti- 
mate may be formed of its excessive destruction among the most helpless class of 
people. The facts on this subject are numerous.* 

These circumstances, taken together with the fact, that, since the people have 
become more attentive to cleanliness, it has never appeared in Europe, show that, 
like common remittents, it is the result of vegetable and animal putrefaction. 

6. Besides, Dr. Hodges states, that after the great plague in London, tlie people 



* See Hosack's Thomas, p. 990, ei seq. 
17 



130 OF THE PLAGUE. 

returned and lived in the houses, and slept in the beds, from which the sick had 
been removed, and which had not been cleansed, without taking it.* 

7. If it arose from contag-ion, where would it stop? it would appear in the cities 
of Europe, as it did formerly: Why does not the cotton of Egypt now produce it 
in Liverpool? De Mertens mentions, that the poor in Moscow wore, during- the 
winter, the woollen clothes of the sick, after the plague had disappeared, without 
taking it. It would never cease in the places where it is endemic, for the same 
practice of buying and wearing the clothes of the dead prevails in Turkey, and 
yet as soon as frost appears the plague disappears, uninfluenced by the breath or 
the contact of the sick and dying. The season, which favours the putrefaction of 
domestic filth, appears to be every thing, and contagion nothing in its produc- 
tion. It may be said, thai: the fact of its inoculation producing death is sufii- 
cient to establish the contagious nature of the disease: It should be recollected, 
that the inoculated were exposed to the atmosphere of the district in which the 
plague prevailed, both before the experiments and after them, and some of them 
were pliysicians continually employed about the sick, so that it is impossible to 
draw any conclusion from them, wliether the disease be contagious or not. 

De jSlertens says, that it was taken from the air, from the contact and the breath 
of the sick. If it was taken from the air, how can it be certainly demonstrated 
that it is taken by contact also; since the effluvium from the body, dead or alive, 
must be diffused in an atmosphere about the person, and must operate before cou' 
tact can take place? The conclusion, then, with regard to its contagion cannot 
be so rigid as strict philosophy requires: The same observation applies to the 
breath; how can we conclude, certainly, that the breath conveys it, when the 
effluvium in the room, which may arise from putrefying vegetable and animal 
matter, is also present: the whole reasoning is g-eneral and crude: the fact, that 
it rises, increases, and declines, as other remittents do, proves that, like them, it 
has the same origin; that is, vegetable and animal putrefaction. The idea that 
the remittents of summer are contagious always prevails in the early periods of 
observation, before tlie facts have been clearly discriminated: thus agues were said 
to be contagious by Cleghorn; also the yellow fever, by those who have not seen 
much of this frightful disease; but where it has been accurately observed, as time, 
now, in the case of the ague, has enabled us to do, tlie idea is not at all generally 
admitted: l"he reader, however, will be better satisfied of the trvith or fallacy of 
the arguments on both sides by consulting the able essays of Dr. Rush on the con- 
tagion of yellow fever, and that of Dr. Ilosack on the same subject. 

The doctrine of contagion deprives the sick of attendance, and they die often 
for want of it: It disarms and petrifies physicians with fear at the very name of the 
plague, and they do not exert themselves to do as much as tliey can for the sick. 
The contrary belief has the opposite tendency: It renders us active in removing 
the causes which produce it, and fearless in reheving the sick. The belief that 
the plague is a fever, gives to physicians the use of their reason; they prescribe 
for it according to symptoms, and will no doubt discover a plan of treatment 
which shall be as successful as that of any other disease: the plague has been cried 
up from the earliest ages, as the most terrible of all diseases: Physicians have never 
much exerted themselves in its elucidation; as far :is the records go, it resembles 
in its origin, and nearly in its nature, the fevers of summer of a high grade; and 
there can be no question that like them, it may be prevented and often cured. 
With regard to the treatment of tlie plague, it is worthy of remark, that the author 
states, that sudorifics and mercury always did good; Sydenham is a great advocate 
for bleeding; taken largely, to fiiinting, it cured many persons: In applying this 
remedy to a disease so violent as the plague, the remarks of Dr. Rush, formerly 
quoted, in p. 94, 5, <o, should be recollected, and applied with judgment; at 
first, when the disease is inflammatory, and in robust and youthful constitutions, 
of which cases are described by Sainoilowitz and others, bleeding will be proper, 
and it should be taken in the decided way mentioned above: in this stage, and kind 
of the plague, the disease attacks the brain, as is shown by the incessant headach. 



Tringle on the Plague, 1722. 



OF THE PLAGUE. 131 

and the furious delirium, from the onset,* continuing- for one or two days, and then 
leaving- the patient feeble and tranquil, death following- in twelve hours. The 
remedy must act immediately, otherwise it is of no avail: This variety resembles 
in its course the yellow fever: It also sometimes attacks the heart; Tlie rules for 
bleeding-, to produce its effects in the highest deg-ree, should be applied thus: we 
should take it the patient being- in a standing- posture, and the blood should be 
permitted to run till fainting- is completely produced; and when the perspiration, 
which follows it. takes place, it siiould be encourag-ed by some diluent drink: The 
plag-ue, it should be recollected, personates every variety, deg-ree, and kind of 
disease, and the practitioner should be on the alert to make use of such remedies 
as the state of the patient indicates. 

The sudorific plan, after bleeding-, Sydenham considered as of the g-reatest im- 
portance; and he cured by it many cases, in which bleeding- was not submitted to. 
As mercury, according- to the author, was valuable, the pl;ui of salivation by cin- 
nabar fumig-ations should be used as more rapid; lately it has been tried, in this 
country, by Dr. Jackson of Northumberland, (Fenn.) with results so decided and 
sudden, that its value cannot be too hig-hly appreciated; for an account of which, 
see the article yellow fever: The value of this mode rests upon the fact, that medi- 
cines applied to the skin extensively produce nearly the same effect, as when 
administered by the stomach; a person immersed in carbonic acid, even thoug-h 
he does not breathe it, is as certainly affected with the stupor and ilrowsiness as 
by respiring- it: mercury, laudanum, and most medicines, may be apphed with 
success in the same mode. C. 



See Samoilowitz, quoted by De Martens, p. 75. London, 1779. 



/P^ 



( 133 



CHAPTER VII. 



INTERMITTENT AND REmTTENT FEVERS. 



Train of Sytnptojns in the Paroxysm of an Intermittent — 
Primary Types of Sgue — Of the Remittent Fever — Conse- 
quences of Jigue — Prognosis — Causes of Ague^ predisposing, 
and occasional — Of Marsh Miasmata — Treatment of Inter- 
mittent Fevers — During the paroxysm — During the Interval 
— Bark — Arsenic — Of the bilious Remittent Fever of warvi 
Climates — Mode of Prevention of these diseases. 

TRAIN OF SYMPTOMS IN THE FIT OF AN INTERMITTENT. 

Intermittents are readily distinguished from every other form 
of idiopathic fever by their occurrence in paroxysms, each of which 
may be considered as an epitome of a febrile disease, exliibiting in 
the course of about eight hours all the stages of fever — its rise, 
progress, crisis, and termination in the recovery of health. This 
circumstance has contributed to give to intermittent fever a large 
share of the attention of pathologists. By an accurate investiga- 
tion of its phenomena, they have endeavoured to arrive at a know- 
ledge of the nature of febrile action, and have imagined they could 
apply to the more varied appearances of other diseases, those gene- 
ral views which the consideration of agues suggested. Distrusting 
in some measure this principle, I commenced the inquiry by a 
sketch of the more frequent, and, in this country at least, far more 
important subject of continued fever. 

The propriety of Ihe epithet Intermit I enty may be questioned on patliolog-ical 
principles. If we analyze the morbid condition of body subjected to the opera- 
tion of the remote cause, we will discover, that althoug'h all the more prominent 
symptoms are generally abated after the three stages noted by the author, tiiere 
is not an entire cessation of the morbid phenomena, but a deceitful temporary 
quiescence. The nei'vous system is weaker than it was previous to the paroxysm, 
the action of the b art dej)ending upon it is weaker: and hence the accumulation 
of blood in tlic hirg*. veins, j)arlicu!arly those of the portal circle, continues to 
increase, while the action of the heart diminishes in the same ])roportion till the 
lieat on the surface diminishes for want of action, and a chill is the conse([uence. 
As the chill increases the excitability accumulates, and as that of the distended 



INTERMITTENT AND REMITTENT FEVERS. 133 

veins is communicated to the heart the hot stage follows necessarily. There seems 
to be no necessity for calling upon the imaginary energies of the vis medicutrix 
naturx to make out our issue in accounting for the phenomena of the disease. 
This position may be illustrated by an appeal to the state of the functions during 
the remission of the symptoms that constitute the tlwee stages. The pulses are 
usually softer, and often more frequent than they are in health, though they are 
sometimes slower, more perfectly natural, as will be manifest to the touch of an 
experienced finger. The tongue is changed, cither in the quantity or quality of 
its secretions. The surface of the whole body is deprived of its healthful appear- 
ance for want of circulation in the capillary vessels, and the condition of the 
abdominal viscera is not that of entire quietude. In many cases the difficulty, with 
which the faculties of the mind are exercised, shows that the wound first inflicted 
on the sensorium, by the remote cause, continues to impair its functions, till an 
entire exemption from its action shall have been effected. If we are not deceived, 
in our rationale, it would be more consistent to say, that it is not the intermittent, 
but the remittent type, that is in nature the archetype of all the family, originating 
in marsh miasmata, for, even between the paroxysms of a quartan, however mild, 
the eye of scrutiny can always find some fault in one or more of the viscera. 

It is impossible for a person, who never witnessed the variety of forms, into 
which intermittents are diversified in warm climates, to estimate their character 
or calculate their danger in the first instance, or their deplorable consequences. 
The latest nosologists have named more than two hundred modifications: and 
almost every physician, extensively concerned in their treatment, must have 
observed fifty others that never have been noticed even by Senac and Alibert, 
whose excellent works have aided us so much in leading to a proper discrimination 
of the symptom.s of ataxique intermittents. We will remark generally, that under 
certain conditions of climate, this disease appears of every degree of fever and 
inflammation, from the mildest quartan ague to phrenitis or apoplexy, which suc- 
ceed to it, as symptoms. P. 

The symptoms which occur in the paroxysm of an intermittent 
fever divide themselves obviously into the cold, the hot, and tlie 
sweating stages; in the course of which, those change^ happen in 
the state of the several functions of the body, which have been 
already (page 44) in part alluded to. The hot stage is usually 
attended with nausea and vomiting, scanty and high coloured urine, 
a hurried breathing, considerable headach, throbbing of the tem- 
ples, confusion of thought, or even delirium. A moisture at length 
breaks out on the face and neck, which gradually extends over the 
whole body, and the febrile symptoms then rapidly diminish. 
The pulse sinks to its natural standard; the feeling of weakness 
goes off; the heat of skin, headach, and thirst abate; the appetite 
returns; the secretions are restored to their healthy condition, the 
urine depositing a lateritious sediment. There is considerable 
variety in the duration of the paroxysm. It is, upon an average, 
about six or eight hours. 

PRIMARY TYPES OF AGUE. 

After a certain interval, the same train of symptoms is renewed, 
and the period of their recurrence gives w^hat is called the type of 
the fever. From very early times three primary types of intermit- 
tent have been observed — the Quotidian, the Tertian, and the 
Quartan, in which the febrile paroxysm completes its revolution 
in the respective periods of twenty-four, forty-eight, and seventy- 



134 INTERMITTENT AND REMITTENT FEVERS. 

two hours. Of these, the most common is the tertian. Several 
irregular types of intermittent fever have been taken notice of by 
authors, such as the double tertian, the semi-tertian, and the double 
quartan, but they are not of frequent occurrence. * There is only 
one other form of the disease which it is necessary to mention 
here. Under certain circumstances, the febrile symptoms, instead 
of ceasing entirely in the interval between the paroxysms, abate 
only to a greater or less degree, and this constitutes the remittent 
type of fever. 

In the course of the disease, it is frequently observed, that the 
type changes; tertians and quartans into quotidians, quotidians into 
intermittents. Under more favourable circumstances, the remittent 
shows the character of an intermittent; and, generally speaking, 
the change into a type of less frequent repetition, indicates an 
abatement in the severity of the disease. Physicians have remarked, 
that the tertian type of fever has its invasion in the forenoon, the 
quartan in the afternoon, and the quotidian in the morning. The 
quartan, which has the longest interval, has the longest and most 
violent cold stage, but upon the whole, the shortest paroxysm. The 
hot fit of the tertian is comparatively the longest. The quotidian, 
with the shortest interval, has at the same time, the longest 
paroxysm. 

Upon what particular circumstances the type of intermittent 
fever depends, has never been ascertained; but, that climate and 
season have great influence over it, and also over the general cha- 
racter of the symptoms, cannot be disputed. Vernal agues, gene- 
rally, assume the tertian type, and are marked by an inflammatory 
diathesis. They are, however, mild, and usually run their course 
quickly. Quartan agues prevail, chiefly, during the autumn and 
winter months, and they are the most obstinate of all the forms of 
intermittent fever, t 



* iMie double tertian with a fit every day, the alternate fits being" similar, or with 
two fits on one day and one on the next: The double quartan, with two fits on the 
first and fourth days only, or with a fit on every day except the third: The triple 
quartan with three fits on the fourth day; or with a fit every day, every fourth fit 
being simihir.t The forms only become interesting" as they show the nature of 
the disease, which is less powerful in proportion to the length of the intervals: It 
therefore determines the necessity of energ-y in our practice, and the danger of 
tlie disease becoming- remittent, fatal or otherwise. C. 

f Tiiat they are difficult to treat is clear, and for several reasons. They are 
occasionally protracted from habit only, and require a strong impression to be 
made to break habitual associations. They are often attended by a small, tense 
pulse in cold weather, without any strong mark of local disease, and can only be 
cured by blood-letting. The most fre(iuent source of difficulty consists in hepatic 
or sijUmiIc afi'ections, which can only be removed by mercury. Whether these 
affections are primary or consecutive, the disease is cured by changing the condi- 
tion of these viscera. 

The affection of the liver or spleen is occasioned by want of proper evacuations 
in the early stage of the disease, and are often occasioned by the premature use 
of tonics, especially the bark. In many cases, the intermittent will recur, irregu- 
larly as long as such local affections exist. P. 

) Thomas. 



INTERMITTENT AND REMITTENT FEVERS. 1 35 

The tertian is the least obstinate form of intermittent fever; for it has neither 
the extreme of excess exhibited by the cold stag-c in the quartan form, nor of the 
hot stag-e in the quotidian; it is therefore more manag-cable: but from the fever 
being- considerable it is of all other forms of the disease most likely to become 
malig-nant, when extreme heat, combined with bad air, marsh miasmata, &c. 
increase the febrile diathesis of the system:* In this climate, remarkable for its 
warm and relaxing- weather, after excessively cold winters, the quotidian, tertian, 
or the remittent form, is most apt to occur in the sjH-ing-, a remark which applies 
also to England, and the latitude of the United States north of us;f the quartan 
form is seldom observed in the spring", in the middle latitudes of the United States; 
Its cold stag-e has been known to last for fifteen hours ;1: its g-eneral duration is 
about two hours: in no part, south of Philadelphia, can the quartan be said to be 
a frequent visiter, as the climate is too warm; on the Mississippi near New Orleans 
it is unknown: It is an important variety of the disease, from its tendency to pro- 
duce obstructions of the liver and spleen, dropsy, fatuity, &c. and from its extreme 
obstinacy; circumstances which render it necessary that stimulants, high and dry 
air, as well as the ordinary tonic plan should be applied: the old bear it badly, as 
also the debilitated; children on the contrary bear it well,§ from the excitable state 
of their blood vessels. 

In Eng-land it has been observed, by Sydenham, that the quotidian or tertian 
forms occur most commonly in the spring-; and that they cease spontaneously when 
the fall sets in, from the influence of the cold weather; tertians, also, which occur 
in the fall cease in the following- spring-: these facts are of importance, as no disease 
is so likely to alarm the patient from its obstinacy, and fatality, when protracted, 
and the constitution is much weakened by frequent attacks: The climate of our 
seacoast so much resembles that of Eng-land, that its diseases have similar charac- 
tei's: another remark made of these diseases in Britain also applies here: their 
spring intermittents, the type being- the same, are less liable to become continued, 
to be accompanied by bilious symptoms, and followed by dang-erous consequences 
than the autumnal, and they are also less disposed to return, l| and the reason is, that 
the heat of the summer debilitates the system and renders it less liable to bear up 
against disease, and favours, by the generation of miasmata during the heat, 
the stronger forms of this disease. The vernal agues require depletion; the au- 
tumnal stimulation; the former it is always easy; whereas it is often impossible 
to stimulate the latter sufficiently, when the system is much reduced.ll C. 

Great as is the influence of season, it is yet inferior to that of 
climate. The remittent type occurs, abnost exclusively, in hot 
countries; but to form an adequate idea of the extent to which the 
symptoms of ague can be modified by climate, it is necessary to 
consult the works of Dr. Cleghorn and Dr. Lind,** authors of the 
highest repute on the subject of intermittent and remittent fever. 

Every thing which illustrates the character of these fevers is important, as it 
enables the practitioner to direct his treatment properly, increasing or diminishing 
the power of his remedies accordingly; When the fits of the quotidian lengthen, 
or those of the tertian reduplicate, it approaches the continued form; the pro- 
traction of the fit, in the tertian, is the most probable evidence of its tendency to 
reduplicate, the cold fit becoming shorter and milder, and the hot fit increasing in 
length and severity: The quartan rarely becomes continued; when it does so, it 
is by a reduplication of its paroxysms; and the new paroxysms are always of the 
same type of the hrst fever. ff The change of these fevers is always thought to 



* Philip, p. 69. f iDici.^. 

i Grant's Obs. quoted by Philip, p. 70. § Ibid!^. 71. 

II Philip, p. 69. If Philip, p. 69, 70. 

** Cleghorn on the diseases of Minorca, 1751. Lind on the Diseases of Hot 
Chmates, 1768. 
ft Philip, p. 73. 



136 INTERMITTENT AND REMITTENT FEVERS. 

be iavourable, as the number of fits diminish in a given time; thus if a quotidian 
becomes tertian i a tertian, quartan; it is in proportion favourable, and vice versa,- the 
violence and the duration of each fit being- less, it is of course more favourable.* 

CONSEQUENCES OF AGUE. 

An ague, sometimes, continues, particularly in cold climates, to 
affect the body for a very long period, without producing any per- 
manent derangement of function or structure; but this is a very 
rare occurrence in hot countries. There the continuance of ague 
induces inflammatory affections of the thoracic or abdominal vis- 
cera, dysentery, cholera, dyspepsia, or chronic ohstriictions of the 
liver and spleen. The tendency of ague to produce an enlarged 
state of the spleen has long been observed, but the cause of this 
peculiarity is as yet undetected. From these organic derangements 
results, as another consequence of ague, dropsy. 

The inflammations which are united with ague, as when it occurs in the form of 
rheumatism and dysentery, are generally the result of sudden vicissitudes from 
heat to cold; the inflamed state of the stomach, which sometimes accompanies it, 
as in the epidemic of Copenhagen, and that described by De Haen, appear to 
result from the action of miasmata evolved by a hot sun: It is more particularly 
in autumn and spring that the complications of an inflammatory cast are observed; 
The indurations of the liver, of spleen, and dropsy, are the legitimate results of 
the disease itself, -f and are owing to no extraneous cause excepting that the debi- 
lity of the ])atient appears to favor them. 

Death happens generally in the cold stage of the quartan, and in the hot stage 
of the other varieties; If the perspiration is profuse it may happen during that 
stage also, and even in the remission, when the preceding paroxysm is violent 4 
The morbid appearances observed after this variety are various; sometimes no 
trace of disease is left; The liver and spleen are often found enlarged, hardened, 
sometimes soft; the former even putrid: The spleen resembles in some cases a bag 
of congealed blood: Tlie pancreas is found enlarged, ulcerated, and oftener indu- 
rated; Bile is found in great quantities in the intestines, the gall-bladder turgid: 
The stomach, omentum, duodenum, and mesentery are found inflamed and 
sphacelated.§ 

PROGNOSIS. 

No general prognosis, in intermittent fever, can be given, which 
is not qualified by reference to the climate, iif which the disease 
appears. In this country, and in Holland, ague is not a disease of 
danger; but at Sierra Leone, and along the neighbouring coast, it 
is scarcely exceeded in malignity by any known disorder. Season, 
also, as I have already stated, affects the general prognosis. It is 
influenced, in like manner, by the previous duration of the disease. 
An ague, which has been present a considerable time, has so far 
rivetted itself in the constitution, that its removal becomes tedious 
and difficult. Relapses, under such circumstances, arc frequent, 
and tend materially to injure the constitution. An ague is more 

• Philip, p. 74. t Ibid. p. 75-6. 

\ Ibid. p. 8.5. § Ibid. p. 93-4. 



INTERMITTENT AND REMITTENT FEVERS. 187 

or less dangerous, in proportion as it is complicated with more or 
less of permanent derangement of the function, or structure of an 
organ. Enlargements of the spleen, from ague, are sometimes 
removed, but they require great vigilance on the part of the prac- 
titioner. . 

This phenomenon, wliich is so troublesome to tlie physician, so vexatious to the 
patient, and often fatal in its consequences, is probably occasioned by a process 
similar to that which gives occasion to hepatic affections which more frequently 
terminate in dropsy, dyspepsia and inflammation of tl;c mucous membranes of the 
intestines. The quantity of blood sent to those viscera in a state of debility g-ives 
rise to venous congestion, which by distension acts as a stimulus to the heait, 
which puts the arteries of the viscera into a state of secreting action. If this con- 
dition of the circulation be not immediately removed, the product of vascular 
action, (which is supposed by some to be febrile, but is more probably sui generis 
according to the peculiar organization of the part,) becomes an organized mem- 
brane, which Is known by the name physconia. This state seems not to take place 
at first, but, unless the secreting process be interrupted, a chronic action ends in 
this state or in dropsy. The enlargement of the viscera is sometimes diminished 
by a sudden copious deposition of fluid in the cavity of the abdomen. The secret- 
ing process, in which dropsy consists, is occasioned by the extension of inflamma- 
tion from the viscera. It som.etimes spreads to the mucous membrane of the 
intestines, and assumes the dysenteric form, but when dropsy is the result, the peri- 
toneal vessels are implicated, and thus ascites is the consequence. These enlarge- 
ments of the liver and spleen may act by pressing on the cava, or veins. The 
existence of the other varieties of dropsy admit of a similar explanation. P. 

Agues, particularly as they. occur in hot climates, are lastly to be 
judged of in reference to prognosis, by the kind of sympitoms 
present, and by the degree of their violence. 

1. From the state of the brain: great dejection of spirits, or anxiety, coma, 
lethargy, snoring, convulsions, or delirium, are unfavourable; the fevers of Ilin- 
dostan, which commence with the latter syijiptom, are particularly fatal. 
• 2. Of the senses. The pupil of the eye, turned inward and downward; false 
vision; insensibility of the retina to light, shown by an immovable iris; deafness, 
are also unfavourable. 

3. Face. Eyes shut and mouth open; dejected or ghastly expression; bleeding 
from the nose and colliquative sweats, are bad. 

4. Bowels. Hard and tumid belly, with a swelling of the tonsils, and painful 
state of the hypochondria and epigastrium; difficulty of swallowing, with afoul 
state of tlie fauces, mouth and tongue; an immoderately dry, a black, or a sodden 
and parboiled, or a white slimy and gelatinous state of the tongue, and pain about 
the upper orifice of the stomach, portend great danger.* Involuntary discharge 
(;if focces, at the same time the bjelly very mucli swelled; black vomit; vomiting 
attended with great anxiety, giddiness, utter dislike to food, with great debility 
and without relief, are dangerous symptoms; as also a colliquative diarrhoea, with 
black discharges. 

5. Heart and respiration: quick, frequent -and fluttering pulse; with a pale, 
shrunk, and contracted state of the skin; a slow and regular pulse, attended with 
coma, are dangerous: a veiy rapid, full, strong and frequent pulse is so likewise, 
though it is more easily controlled than the foregoing symptoms.f The respi- 
ration panting, anxious and hurried, also sighing and groaning, are bad symptoms: 
hiccup and interrupted breathing, loss of speech, or great change in the voice, are 
so likewise, 

6. Urine. Dark, depositing a black or brown sediment, at the same time that 
the eyes are suffused with blood, also an involuntary discharge of urine are 
dangerous. 



* Philip, p. 80. + Ibid. 

IS 



13S INTERMITTENT AND REMITTENT FEVERS. 

7. Skin. Partial, cold sweats, blotches like the stings of nettles, coldness of the 
skin, also its insensibility, shown by flies settling op the hps and eyes, and cadaver- 
ous perspiration are unfavourable. 

8. General character of all the symptoms. Long- intervals, and short fits are, in 
proportion, void of danger; a quotidian is most dangerous, a quartan least so.* 
The fits becoming milder are favourable: in general the mildness of the fits, rather 
than the completeness of the interval, give the better criterion of safety. 

9. Diarrhoea, vomiting, coma, &c. or any of the bad symptoms above enume-: 
rated, continuing during the remission, are dangerous: Cutaneous eruptions, as 
the small pox, miliary eruptions; salivation; herpes or ulcers on the lips or ears; 
profuse warm sweats are favourable, and. often remove the disease. t If the inter- 
mittent be complicated with the symptoms of apoplexy, epilepsy, or any other 
disease, the prognosis is to be taken from that, which distinguishes these diseases. 

Any cause of debility is dangerous; age, intemperance, debilitating chronic 
diseases are bad precursors, the intervals becoming longer, malignant symptoms 
subsiding, the patient more easy in the intermission, youth, temperance, the 
disease being of short duration previously, are favourable. C. 

• CAUSES. 

The circumstances which predispose the body to an attack of 
intermittent fever have been detailed by authors with great minute- 
ness, but there are only a few which are of any practical importance. 
Certain states of the air favour the disposition of the body to 
receive ague, rivet it in the constitution, baffle us in our attempts to 
cure the disease, and induce a tcndcrrcy to relapse from the appli- 
cation of slight causes. Of these, the most remarkable are the 
concurrence of a cold with a moist state of atmosphere, the preva- 
lence of an easterly wind, and the night air. Of the last of these, 
it is highly important, in a practical point of view, to appreciate 
the full influence. Dr. Lind,* whose opportunities of observation, 
were very extensive, lays much stress upon it. He urges the 
danger of sleeping, or remaining all night in aguish situations; and 
in his Essay on the Diseases of Hot Climates, illustrates this by 
many apposite examples. 

Weakness of the body, whether owing to a poor and unwhole- 
some diet, long watching, fatigue, severe evacuations, or previous 
diseases, augments the disposition to ague. Hence it is that it 
prevails with so much greater frequency and virulence in camps 
than in any other situations; particularly after g severe campaign, 
when the'men have been hard worked, and exposed to great priva- 
tions. There is reason to believe, that the disposition to take ague 
is affected by certain states of the mind; anxiety and inactivity 
increasing it, while hope and confidence, and whatever can excite 
the energy of the mind, lessen the susceptibility. An army is 
generally most free from ague while actively engaged in military 
pursuits. 

The last circumstance which deserves to be mentioned in an 
enumeration of the predisposing causes of ague, is Ar/A<7, 'or the 



•Phihp, p. 81. flbid. 



INTERMITTENT AND REMTTENT FEVERS. 139 

• tendency which previous attacks give to a recurrence of the com- 
plaint. In this circumstance, intermittent fevers dififer from 
continued, where one attack lessens the liahility to a second; but 
it is a principle in patholoo;y, which, though inapplicable to con- 

■ tinued fevers, is yet found to influence the phenomena of several 
other febrile diseases; sore throat, for instance, erysipelas, and 
dysentery. So powerful is its effect in ague, that very slight 
causes are sufficient to rCnew the paroxysm, when long habit has 
left a predisposition in "the system. It even serves to give an 
intermitting character to other diseases. 

MARSH MIASMATA. 

The great and important occasional cause of intermittent fevers 
are exhalations from soil, especially from marshy grounds, called 
by ph3''sicians Marsh Miasmata. It is certainly a curious fact, 
that this pathological principle, so obvious, and so important in its 
practical tendency, should have been unknown to, or at least 
unnoticed by the older medical authors. Sydenham seems to have 
had a glimpse of it, but he could not have seen it in its true light; 
for, in his fifth chapter, he attributes agues to the ebullition of 
spirits and viscid juices. Lancisi is the original writer on marsh 
miasmata.* We are still far from being fully acquainted with all 
the circumstances upon which the production of ague depends. It 
is presumed, however, that the miasmata arise from the combina- 
tion of earth and moisture with putrescent vegetable matter. 
Moisture, alone, though ever so abundant, will not produce ague, 
for it is a rare disease at sea, even upon the foggy banks of New- 
foundland. When the marsh is covered by water, agues are less 
frequent. Of the exact nature of these miasmata we are ignorant; 
but some points have been noticed with regard to them, which it 
will be proper to advert to. 

The most elevated part of a marsh being always the healthiest, 
it is imagined that the miasmata are comparatively heavier than 
atmospheric air.. There is reason too to believe, that they cannot 
be wafted by currents of air to any gr^t distance from the spot 
where they were generated, but on this point some differences of 
opinion have lately prevailed. The calm months of the year being 
the most productive of agues, it is reasonable to suppose, that the 
'miasmata are most powerful when concentrated, and that diffusion 
by a brisk wind renders them comparatively inert. Culture and 
proper draining prevent their formation, and hence it is that inter- 
mittent fevers are so much less frequent in England at present than 
they were formerly. A very short exposure to the exhalations of 
a marsh is sufficient to aflfect the system. Travelling through the 



* His treatise is entitled " De Noxiis Paludum Effluviis, 1717. 



140 INTERMITTENT AND REMITTENT FEVERS. 

Pontine Marshes has often been followed by ah attack of ague. 
There is considerable diversity in the period which elapses between 
exposure to marsh miasmata,' and the invasion of the disease. It 
sometimes does not exceed a few days, but there is reason to believe 
that the latent period has occasionally extended to several weeks, 
or ev^en months. 

Mlasinata produce various efTccts, which exhibit modifications necessary to be 
noticed. 1. The inliabitants of marshy situations afe seldom long-lived; thus at 
Peterborough, in Virginia, it is said they die at the age of t\vent}-one. In some 
parts of Georgia fifty is the extreme period of human life. 

2. "NVhen moderate in degree, miasmata produce intermittents; when more con- 
centrated, remittents; thus, in Jamaica, in the most healthy seasoris, the fevers. are 
intermittent; in the rainy and other unhealthy seasons remittent.* The ague 
appears, for this reason, in cool seasons, as spring and autumn, and in temperate 
latitudes; remittents in summer, and in tropical countries. 

3. Sudden changes, from cold to hot weather, favour the production of inter- 
mittents :t Thus, in Holland, cold and wet ^yeather in autumn, after a very hot 
summer, renders agues more general and more malignant: Here the cold acts as 
an exciting cause, bringing into action the miasmata. Cold damp nights, succeed- 
ing hot days, produce the same effects: moisture and cold singly have no agency 
in producing- agues, for it is observed tliat moist and mild winters in England are 
the most healtliful; and at sea these diseases do not appear; they are not found also 
in high latitudes, when the temperature is below 30°, The circumstance that 
soldiers, encamped in woods, take these diseases, is explained by the miasmata 
generated in these situations: In hot climates, wooded shores are particularly dan- 
gerous; a few hours exposure is sufiicient to induce the most violent fevers. 

4. The nearer to the ground, the greater is the danger: Thus, Prir.gle observed, 
that in Holland soldiers on the ground floor were more liable to agues than those 
upon the second story; those upon the third less than those upon the second. The 
same is observed of the plague in Aleppo. 

5. "Woods are thought to intercept the pernicious effluvium: an important cir- 
cumstance in choosing a site for encampments,:^: dwellings, &.c. C. 

But though it cannot be disputed, that the miasmata of mars/ies 
are the most frequent and important exciting causes of intermittent 
fever, still it would be impossible to deny that it has others. 
Febrific miasmata may unquestionably arise, under particular 
circumstances, from almost any soil; and the disease which they 
excite has, I believe, in nearly all cases, a tendency to exhibit the 
phenomena of interniissioiiy or at least of very well marked 
■ remission. Persons residing in very healthy parts of London, 
are occasionally attacked by intermittent fever. In the time of 
Sydenham, agues were common in every part of the metropolis. 
To the great attention which is now paid to the sewers, w^e are, 
probably, in a considerable degree, indebted for the ])resent healthi- 
ness of the town, and particularly for our exemption from ague. ' 
The occasional occurrence of the disease, therefore, at a distance 
from marshes, is not to be a matter of surprise. Agues ])rcvail 
extensively in certain districts, where tliere are no marshes; but 
tlicn it will always be found, that there is something ccpiivalciit to 
a marsh. There is either a subsoil of such a nature as does not 



•hilip, p. IV. t J^i<l- P- 98. 4 Ibid. p. 101. 



INTEKMITTENT AND llEMITTENT FEVERS. Ml 

allow water to percolate easily through it; or there is an extent of 
wood, impeding thorough ventilation, and the action of the sun's 
rays; or there is a total inattention to drainage and culture. In. 
one or other of these ways, we may be .able to explain the preva- 
lence of ague, in the uncultivated parts of America, and in many 
parts of Italy and Sicily, particularly the' neighbourhood of Flo- 
rence, Rome, Naples, and Syracuse. 

These peculiarities of soil are not merely the occasion of agues, 
but they serve to modify the character of continued fever, and of 
any other febrile disease which may happen to occur in the district. 
This principle in pathology we have already, had occasion to allude 
to, when treating of continued fever. They give a tendency to 
exacerbation and remission in the symptoms of the fever; and it 
is not improbable, that many cases of what might be considered 
genuine remittent fever from marsh exhalation, are, in fact, cases 
of common continued fever from cold, modified by peculiarities of 
soil. • ■ . 



TREAT3IENT. 

Before entering on the method of treatment, in intermittpnt 
fevers, I may shortly advert to this question of the relation in 
which they stand to continued- fevers. It is contended by some, 
that intermittent and continued fevers are closely allied in their 
nature; that the operation of their exciting causes is in everv vvay 
similar; and that the same treatment is applicable to both. There 
are pathologists, on the other hand, who maintain that intermittent 
and continued fevers are essentially different from, each other, and 
consequently that there are essential differences in the principles 
of their treatment. ,Our knowledge of the pathology of fever is 
hardly sufficient to authorize a decided opinion of the speculative 
question at issue, but it is certainly better for the student to view 
them as distinct classes of disorders. 

It has been made a question whether agues ought to be cured. 
'An idea has prevailed in many aguish countries, that there was 
something salutary in the fever. Boerhaave himself, a physician 
of great genius, was misled by this prejudice, and not satisfied with 
the negative merit, that agues do no harm, and may therefore be 
suffered to continue, speaks of their positive advantages.* ' These 
opinions no longer prevail; and the only question wliich they now 
suggest is, whether, under certain circumstances, it may bo proper 
to allow the type of the fever clearly to develope itself before bark 
is given. 



* Cseterum, nisi malig-na;, corpus ad longjevitatem disponunt, et depurant ab 
inveteratis malis. Boerhaave. Aphor. 754. 



142 INTERMITTENT AND REMITTENT FEVERS. 

Thoug-h the opinion, above expressed, is certainly true, yet notwithstanding", 
after the influence of diet, exercise and medicine, tog-ether witli* the chang-e 
probably produced by the disease, it is certain, that persons after a long- attadk of 
•the ag-ue improve much in their g-eneral health; yet as interralttents are often 
mortal, or end in incurable chronic maladies, they should undoubtedly be arrested 
as soon as possible, excepting- (in the opinion of some) in certain cases, such as 
where chronic diseases, as mania, epilepsy, cutaneous diseases, dyspepsia, g-out, 
asthma, palsy, have long- afflicted the patient; then, they contend, that asinter- 
mittents have sometimes cured them, the experlraentof slowly altering- the system 
may sometimes be tried; with what justice, experience, as yet, is not sufficiently 
ample to prove: a. feature of this opinion, more important in a practical point of 
view, is the propriety of curing an ague at once, or the postponement of the use 
of remedies for some time: The latter was the opinion of Boerhaave, but as hepa- 
tic and splenic cong-estlons^ and jaundice, are the results often of only a few fits of 
ag-ue, it is necessary to cure it at once, and in doing this there will be no danger, 
if v. S. purgatives, Lc. are properly employed, .C. 

Another erroneous notion respecting the treatment of agues has 
frequently been avowed; namely, that their management requires 
little or no exercise of professional skill. So far is this from being 
the case, that agues often baffle the best directed exertions of our 
art. They become complicated with other diseases; their symp- 
toms are modified by climate, season, and habit of body; nor can 
their treatment be properly adapted to these different circumstances, 
except under the guidance of pathology. It is true, indeed, that 
the hypothetical views of authors, regarding the proximate cause 
of intermittent fever, give us no assistance whatever in determining 
the treatment; but the pathology which is subservient to practice, 
is altogether of a different character.- The practice in agues, then, 
it may be observed, is to be regulated in many respects by the 
same principles which direct us in the treatment of continued fever. 

In considering the method of cure, in intermittent fevers, their 
tendency to spontaneous termination must be borne in mind. 
Hippocrates, in the very dawn of medical science, took notice that 
tertians, particularly in the month of July, often terminated, 
without the aid of medicine, within five, seVen, or at most nine 
revolutions; and modern experience has confirmed the observation.* 
Mild vernal tertians will frequently go off spontaneously; but 
though this tendency is to be kept in view, that the practitioner may 
feel he is working with nature, and not against her, it is by no 
means to check his efforts to put a speedy period to the disease. t 



* Vide Cleghorn on " the Epidemical Diseases of Minorca," page 205. 

f A spontaneous termination of intcrmittents is a rare occvu-rence, and scarcely 
happens, except in one special condition of the system; and this might have been 
the case with Hippocrates, although he docs not mention the fiict. M hen an inter- 
mittent has appeared in autumn, and is suspended in winter, it very frequently 
recurs in April, May or June, and sometimes seems to be cured by the renovating 
influence of heat. This happens in June and.luly," and sometimes In May, if the 
temperature be unusually high. Tills will not be a fortunate termination of the 
case, if the abdominal viscera arc imphcated in the diseased action. P. 



INTERmTTENT AND REMITTENT FEVERS. 143 



TREATMENT DURIN'G THE FIT. 

The treatment of ague divides itself into two parts, the pallia- 
tive and the curative;. in other words, the treatment during \\\^ 
paroxysms, and in the intervals between them. During; the 
paroxysm, the object of the practitioner is to hasten its different 
stages, and to relieve urgent symptoms. . In the interval, the 
indication of. cure is to prevent its return; and this either by 
strengthening the body, or more properly, by producing such an 
effect upon it, and particularly upon the nervous system, as may 
prevent the developement of fever. As we are altogether unac- 
quainted with the manner in which marsh miasmata produce agues; 
so in like manner must we profess our ignorance of the exact 
modus operandi of our febrifuge medicines. 

In some ag-ue's no treatment whatever is necessary; thus, when a person comes 
out of a miasmatic to a pure air, it disappears without the use of medicine: The 
agues of Delaware are cured by the air of Philadelphia; Sydenham mentions that 
the intermittents of the spring- are often rendered more obstinate by bleeding" and 
purging- in Eng-land, and that it prolong-s them to the autumn; the old saying of 
King James, that 

" An intermittent in the spring 
■ Was phN'sic for a king," 

though perhaps exaggerated, shows at least the tendency of agues to a sponta- 
neous termination in that climate, and the necessity of withholding- medicine 
rather than administering it; The same author states, that a quartan taken by a 
person who has had it before, though long since, terminates spontaneously by a 
few fits, of whatever age or constitution he may be;* Some moderate evacuation 
in vernal agues, as a vomit followed by an opiate; a sweat, or a few enemata, may 
be used, if the patient will not be satisfied without taking some medicine. f 

In the cold stage, stimulants, w^arm diluents, and the pedilu- 
vium may be had recourse to. 

. The patient maybe put into a warm bed with bottles filled w'ith hot water, 
applied to his ancles, thighs, and kidneys; or rubbed with a flesh brush till a glow 
is excited on the skin. Lying in the hot sun, during this stage, has a good effect: 
this is a plan which may be useful where the other means cannot be had. The 
drinks should be hot, but not stimulating, as they endanger the safety of the patient, 
in the hot stage, by producing too great excitement: cordials, stimulants, tinctures, 
spices, &c. are therefore to be avoided. 

The shower bath has been advised to hasten the termination of. the cold stage, 
but Nvithout sufficient evidence of its efficacy. In debilitated cases, it would be 
certainly dangerous; in the robust it might probably answ.er: but I would by no 
means advise it, though I have heard of cases in which it has been used success- 
fully :. If it operates by the shock produced by the sudden aff"usion, a shower bath 
of water as hot as the patient could well bear it, would produce this effect, without 
the danger of increasmg the chill; but of the usefulness of this measure I have 
no experience. 

Emetics are used with the view of bringing on the hot fit; They should be given 
soon after the beginning of the cold stage; and for this purpose tartrite of anti- 
mony, given in the dose of six grs. to two quarts of warm water, will be proper, 
drinking half a pint every ten minutes till it operates freely; it produces vomiting 
and a free discharge of the bile in the cold stage, where vomiting is proper, and 



Rush's Sydenham, p. o^-7, note, &c. f Ibid. 



144 INTERmTTENT AND REMITTENT FEVERS. 

when the hot stage comes on it purges freely; a mode of evacuation best suited 
to the rehef of the fever. 

If there should be delirium or coma, a mus'tard poultice, applied to the back of 
the neck, should be prescribed; and if at the same time tlie head be hot and the 
feet cold, the pediluvium in addition will be usefal. . . 

Dr. Munro mentions a case in which the paroxysm consisted of a succession, of 
chills, without being followed by a hot fit: t!ie cold bath in the intervals, and cor- 
dial tonics during the fit, cured the patient. 

In the hot stage, cold acidulated drinlt, and saline diaphoretics 
are proper; of these, the following are the most advisable: 

Spiritus mindereri, ^ss. every half hour; or ten grs. of salt of tartar, in a table 
spoonful of vinegar, at the same interval; ten grs. of nitre with l-6tli of a gr. of 
tartar emetic, or a gr. of ipecacuanha, will answer; with tepid diluting drinks, as 
warm chamomile, or cupatorium (perfoliatum) tea; lemonade; a drink acidulated 
with elixir of vitriol; or barley water \vith vinegar; vinegar whey; a solution of 
•nitre in ^i. to the pint of linseed tea. Excessively stimulating articles shsuld be 
avoided m exciting. perspiration during the hot fit, particularly in violent plethoric 
and inflammatory systems; and when the liver and .spleen are affected. The use 
of some of the above drinks in these states are particularly valuable, for instance, 
the eupatorium, from its purgative cfl["ect: active and direct depletion is in these 
cases always advisable. • • . * ' 

Ti\e prepamtions of antimony; as James' Powder,, or the tartrite, combined with 
small doses of opium are valuable, when assisted with diluent drinks, and a warm 
bed. The James' powder, combined with calomel, according to the original prac- 
tice of Dr. James, i§ a good medicine*: The povcrs powder does not answer so 
well,* not, however, as has been alleged, from the circumstance that it contains 
opium, for this drug given in the hot fit of intermittents and remittents, in which 
the action is not too high, prodiices a perspiration. 

Two practices ho\vever of a peculiar nature have been recom- 
mended in this stage of the disease, which require particular notice. 
The first of these is the employment of blood-letting; and much 
controversy has taken place as to its propriety, even from the time 
of Celsus. ' We have the assurance of Pringle and Cleghorn,t 
that in warm climates and seasons, it is a safe and proper practice, 
rendering the intermission or remission more complete, taking off 
that inflammatory diathesis which counteracts the beneficial effects 
of bark, and removing those pleuritic and rheumatic affections, 
and those symptoms of congestion in the brain, . which are some- 
times complicated with ague. The blood drawn .in the hot fit of 
an ague frequently exhibits the bufiy coat. 

Bleeding in the hot fit without regard to -quantity till the reaction is reduced, 
is advised by Dr. Cooke of Virginia; after it purgatives act more easily, and the 
bark lias a better effect: violent local pains, a strong inflammatory diathesis, a full 
hard pulse indicate it strongly. It relieves this state, when purges have no effect, 
and sometimes entirely cures the disease: Dr. Cooke even recommends the wai-m 
bath or emetics, MJien the pulse is low in the liot stage, preparatory to bleeding; 
whicli is then drawn largely witli the happiest effect. 

The fits are rendered shorter, it abates the fever, delirium, pain in the head, 
bowels, limbs and chest, and the profuse sweats: Witliout it, the fever becomes 



* Philip, p. 113. 

t Pringle on the Diseases of the Army, page 200. Clcghorn on the Diseases of 
Minorca, p;ige 197. 



LNTERIkUTTENT AND REMITTENT FEVERS. 145 

obstinate itnd the bark dang-erous from its stimulating- quality.* Sometimes it is 
necessary to repeat the venesection several times. Dr. Johnson advises bleeding- 
till the head and prscordia are relieved, without regard to quantity, taken particu- 
larly in the height of the fit, and drawn into the centre and not against the sides 
of the basin which should be smooth, otlierwise the inflammatory buff does not 
appear. C. 

Dr. Lind speaks in the most favourable terms of the exhibition 
of opium in the hot stage of ague. He recommends the opiate to 
be administered about half an hour after its commencement, and 
he states, that it shortens and abates the fit, relieves the hcad-ach, 
which is always so urgent a symptom in this period of the disease, 
and brings on a profuse sweat with an agreeable softness of the 
skin, ending in a refreshing sleep. Dr. Lind is entitled to great 
confidence, for he was an accurate observer, and his opportunities 
of seeing the disease under all its modifications were very exten- 
sive, t 

OF THE MODE OF PREVENTIXG THE PAROXYSM. 

In the interval, I have already remarked, that the indications 
are more obscure. It is commonly stated, that the object is to 
give tone to the system; but the acknowledged efficacy of arsenic 
in the cure of agues does not countenance such an opinion. The 
precise effect produced upon the body by those drugs which are 
the most powerful in curing agues has not been ascertained. They 
appear to concur in producing some strong impression upon the 
nervous system, which prevents the developement of fever. This 
idea is corroborated by the consideration, that the nearer they can 
be given to the expected period of the paroxysm, the more certain 
is their effect. An emetic administered immediately before the 
accession of the cold stage is very serviceable. 

R. Ipec. 9i. 

Aq. Menth. Satlv. 5s. 
il. ft. haust. 

A strong opiate, especially in combination with aether, as in the 
antispasmodic draught given below, has frequently succeeded in 
checking the paroxysm, on its first approach. 

R. Mistur. Camph. ^x. 
Tinct. Opii. gtt. xl. 
Spir. aeth. Sulphur, ^i. 
Syrup, rhaed. 31. 
M. f. haust. 

Sometimes an ounce of bark g-iven immediately before the fit not only prevents 
it, but cures it altogether; the warm bath also is useful. 



* See Senac, p. 170-1. Cleghorn, p. 197-8., and R. Jackson on fevers of S. 
Carolina. 

f Dr. Rush also gave opium with success, in the bilious fevers of 1780; tb« 
type must be moderate, and not inflammatory in order to its success. 
19 



146 INTERMITTENT AND REMITTENT FEVERS. 

The volatile alkali may be used with the same intention. Vari- 
ous remedies of a similar kind, consisting principally of combina- 
tions of spirit and aromatics, have acquired great reputation with 
the vulgar. They agree in producing some strong impression 
either upon the stomach or external senses. 

Berg-ius gave six gvs. of the capsicum with ^ii of bay -berries in powder before 
the cold fit with effect: He abo used g-arlic and mustard seeds at the same period: 
the objection, however, to all these stimidating- plans is, that if they do not succeed 
they ag-g-ravate the fever. The plan of Dr. Fordycc, where this is anticipated, of 
giving- 15 or 20 grs. of Dovers powder with carbonate of ammonia so as to excite a 
sweat before the cold fit begins is very efr'ectual. To favour it, warm cloths, and 
about 40 minutes or an hour after diluents should be used: as, if any drink be 
taken immediately, it excites vomiting. Two drams of myrrh, taken before the 
fit, suspended it, in the practice of Dr. Heberden. Exercise on a hard trotting 
horse, walking rapidly or any kind of labour, the carbonate of ammonia, in the 
dose of 3 or 4 grs. also stop it. — The application for 15 minutes of tourniquets to a 
leg or arm, so as to compress the blood-vessels, prevent the fit, if used before it 
appears, or on its approach: a tourniquet applied during the cold fit hastens the 
access of fever. The patient should avoid going into cold air, washing his hands 
in cold water, or sitting in a breeze if the fit is expected. C. 

MEANS USED DURING THE INTERMISSION. 

The most generally successful, however, of all the means which 
have been resorted to for the cure of intermittent fever, is the 
exhibition of bark and arsenic. 

An emetic of one gr. of tart, emetic, xx of ipecacuanha; or xxv grs. of the lat- 
ter alone, followed by a purge of calomel and jalap, 10 and 10 of each; or of 25 
grs. of rhubarb with 5 of calomel should precede the use of the bark; and if the 
system be feverish, the pulse quicker than usual, with a white tongue and dry 
skin, v. S. will have a good preparatory effect; In old persons an emetic given 
before the fit, where there is danger of death from the paroxysm, sometimes hap- 
pily prevents it. 

The species which are most relied on, are the cinchona oblongifolia or the red 
bark, lancifolia or pale bark, and lastly the cordifolia or yellow bark which is the 
most powerful. C. 

Bark is most effectual when given during a state of perfect apy- 
rexia, when exhibited in the form of powder, in large doses, and 
as near as possible to the expected paroxysm. One or two 
drachms may be taken every hour for six or eight hours previous 
to the fit. Mucli certainly depends on the qxLanlity administered 
in a short space of time.* 

Dr. Fordyce says, if taken during the hot stage, it increases the length of the 
paroxysm, and renders the termination of the disease less favourable.f The com- 
mon effect of stricture across the breast, and difficulty of breathing', which the 
bark produces, shews clearly its stimulant power, when given during the apy- 
rexia: During the fever, its effects must of course be more decided: Great weak- 
ness is the only case, which forms an exception to its exhibition during the fit. 
With regard to the quantity given during the apyrexia, its good cfiTect certainly 
depends upon it: During the period, when the bark was considered as a dangerous 

• On this subject, experience is decided; It was the opinion of Dr. Clcghorn, 
that given during the fit, it destroyed life; owing, no doubt, to the highly excited 
state of the system, produced by th.e heats of Minorca. 

i Philip, vol. i. p. 131. 



INTERMITTENT AND REMITTENT FEVERS. 147 

medicine, it was customary to g-ive it in minute closes. Sydenliam gave it in small 
doses and at long" intervals, a practice, which more recent experience proves to be 
injurious: IJrocklesly speaks hig-hly of it, in large doses, in obstructions of the 
liver and spleen, after a free use of emetics and cathartics: The latter medicines, 
by ag-itating- these viscera, promote the return of blood from tliem, whilst the 
bark strengthens the system and gives power to the arteries, and thus the venous 
stagnation, on which these obstructions depend, is obviated. In the opinion of 
Lind, when given in large doses, it prevented the dropsy, jaundice, or violent 
headach, which were proportional to the number of fits which preceded; without 
the bark given largely, these consequences certainly followed: Dysentery, dropsy 
and obstructions of the viscera were always most common, in the observation of 
Dr. Jackson, when the bark was sparingly employed. Storck found it the best 
remedy for the latter affections, occuring after ague. If the apyrexia is short, the 
doses should be large and frequently repeated; if the intervals, however, are 
longer, the doses may be smaller, and more protracted: In England, two ounces 
in the opinion of Dr. Millar, after the experience of a long life, were sufficient to 
prevent any mortal consequences; the same remark is confirmed by others. C. 

All means therefore should be taken to prevent its disagreeing 
with the stomach, or running off by the bowels. For this purpose 
it may sometimes be advantageously united with an aromatic, or 
with opium, or a few grains of rhubarb; or the form of decoction 
and extract may be substituted for the powder. 

R. Decoct, cinchon. ^ss. extract, cinchon. gr. xv. tinct. cinchon. 51. M. ft. 
haust. 

To children, it may be administered with laudanum in the form of clyster pre- 
mising a purgative: the sulphate of quinine, also may be given between two 
wafers, made by dropping a fluid paste of flour and water on a hot smoothing 
iron, and then compressing it with another, heated in the same way, as recom- 
mended by Dr. Cartv/right. This mediciiie relieves agues in the dose of a quarter 
of a grain in adults, and in this mode will be found very agreeable and effectual; or 
bark may be applied externally quilted in a waiscoat, or in poultices to the legs 
and arms: Two or three grains of the sulphate of quinine every two hours is the 
common dose for an adult: Ten drachms to a pint of sherry wine, make a good 
tincture; it may be given in the dose of a wineglass full thrice a day: as astringents 
are sometimes given in ague, it should be recollected that they precipitate the 
quinine and therefore are improper vehicles for it: Cream of tartar decomposes it. 
It may be given in sulphuric acid in the proportion of a minim to every grain of the 
salt: Dr. Hosack recommends the combination of the bark and citric acid as most 
valuable next to the sulphate. With regard to the bark, it is best g-iven in milk, 
washing the mouth with it afterwards, or with liquorice; to soldiers and sailors, 
brandy and water or porter, is the most agreeable vehicle. 

Its infusion and decoction should be prepared in vessels with narrow mouths, 
kept from the air and used soon, as Fourcroy tells us its active matter is precipi- 
tated by combining with oxygen, and will often be found to be capable of being 
exhibited with laudanum or wine, when the powder cannot be borne. I'he pow- 
der, after the sulphate of quinine, is the most effectual: Barry's extract, which is 
prepared by evaporating the decoction in vacuo is the next valuable. Sometimes 
the tincture from its alcohol is more valuable than any other form: Its efficacy is 
increased also, as the author states, by various additions. 

T. In simple ague without local affections; Cascarilla, serpentaria, carbonate of 
ammonia, camphor, mustard, the alkalies, cloves, cinnamon, opium, are recom- 
mended: These tonics and stimulants are particularly useful when age, debility, a 
damp situation, a rainy season give the disease a more obstinate character, or when 
the stomach is weak. The serpentaria, with the salt of tartar particularl}' lias been 
useful : the following prescription is recommended on the authority of Dr. Lind. 
R. Cinchon. pulv. ^ii. sal. tartar, et. serpentar. Virgin, a gr. xii. M. detur quaque 
hora. Seven or eight doses effectually prevent the fit; and given for seven or 
eight days, no relapse occurs.* The following formula is also valuable; R. Cin- 

* Lind on the Diseases of Hot Climates, p. 77. Phil. 1811. 



148 INTERMITTENT AND RE\HTTENT FEVERS. 

chon. pulv, ct potass, supcrtartrat a .^i. caryophyll. contritor. No. xxx. M. Dose — 
giss every tliird hour. 

The Virg-inia snake root and myrrh may also be combined with the bark; equal 

})arts of bark and the fbnnei-, with ►^i of the latter every two liouis: Lind sjieaks 
lig-hly of fifteen f^rs. of alum, ten of nutmeg-, and ten of extract of bark ^[■iven twice 
a day. Five jr-rs. of caniplior with a drachm of the bark, or three ^rs. of carbonate 
of ammonia with the same quantity, or a g-r. of opium UKiy be piven wlien the 
system recjuires support, the habit is phleg-uiatic, and in quartans: The tincture is 
then pai'ticularly useful: also in the form of Julep witl^ ^ brandy: and if spirits be 
not ag-reeable, the vol. spirits of anmionia and ten drops or a dram of the tincture 
of myrrh may be g-iven witli cacli dose: mustard is combined with the bark in the 
quantity of ten or twenty g-rs. with g-ood effect: In simi)le agues the above medi- 
cines ar'-est it, and prevent the violent headachs, vertig-o, jaundice, swelling's of 
the liver and spleen, so often tiie result of its return. V\ hen tiiere is g-reat de- 
bility in the intei'vals, a cordial diet, with wine and steel arc useful. 'I'he eflicacy 
of the b:irk is also increased by other medicines.* 

li. >\ hen hepatic disease is combined with it; calomel in doses of a g-r. every 
nig-ht and morning- so as to affect the mouth and keep the bowels open, is a 
valuable assistant: The muriate of ammonia, combined with the bark is also highly 
praisedj Purg'es of sulphate of potash with senna, rhubarb also are useful, in this 
case.f 

III. The combination of other medicines and plans increase its eflicacy, when 
the stomach is out of order. A sense of heaviness, tightness of the chest, and 
sickness at the slomueh indicate this st;ite:t An emetic, and a purgative, and then 
the bark, g-iven in the form of enema, succi-eds well: or salt of tartar grs. iv. with 
8 or lU dro|is of lauthunim, in a table spoonful of vinegar, every two hours; or salt 
of tartar and lemon juice .'§1 The combination of aromatics, in this case, is also 
valuable, after the u?e of emeticf: and purg-atives. When the bark produces sim|>ly 
sickness at the stomach, the elixir vitriol, or a dose of laudanum alone, or united 
with camphor often relieves it. 

IV. When it produces excessive ])urging-, eight or ten drops of laudanum, with 
5*1. of chalk, with 10 g'rs. of aliun, extract of logwood, kino, or catechu, nuiy be 
g-ivcJi in union with tlie sulphate of (piinine, or with the infusion, decoction .or 
])Owder of the l):uk; after excessive j)urg-ing-, by the bark, the next fit is often 
more severe; the disease then becomes miUler and often disaii()ears. This is true 
in some instances; it has, however, been observed, that notwithstanding- the purga- 
tive or emetic operation of the bark, the next lit has been miUler, and the lebrifugc 
properties of that medicine entirely uninjured. 

V. When coug'h is combined with ague, blisters to the breast, venesection, 
linseed tea, decoction of mallows, mucilage of g inn Aral)ic, syrups; with nitre and 
other sudorifics. (iroaning-; anxious respiration, proilucing sudden waking, par- 
ticularly in a recumbent posture; cough; pressure on the intercostal muscles giving 

!),iin, are signs, which will enable the physician to judge of the jjresence of this 
ocal affection: he shoukl, more particularly, attend to the state of the thoracic 
organs during the fit; as, if the fever runs high, the face is red, with great external 
heat, thirst and strong pulse, by the ])atients account, he will, when during the 
fever every function is strained to the utmost, be able to find out the weak part, 
which bears worst the onset of reaction; this remark :q>plies to all other cases of 
local affection. II 

Vi. Costivencss; or brown, black, or bilious stools indicate the combination of 
purgatives, emetics, and diluents.1[ 

When the symptoms arc violent, the bark will be more efHcacious by other 
combinations. 

It nuist, then, be given at shorter intervals; and connnenced as early as possible; 
if the bowels are costive, ])urgatives of calomel and jalap, or rhubarb, senna and 
manna; if the mouth and skin be dry, with febrile sym|)ton)s, in the intervals the 
combination of 10 or 15 grs. of nitre: or of salt of tartar J^i. and lemon juice or 
vinegar .^ss. or the spiritus mindereri .^ss., with each dose, will be salutary. 

* Med. Recorder, p. 530. vol. viii. t Ibid. 

I Senac. § Ibid. 

II rhilii). i Senac. 



INTERMITTENT AND REMITTENT FEVERS. 149 

Vin. When the symptoms are malig-nant, attended with either coma, stertor, 
syncope, stupor, convulsions, f^reat debility, facies hippocratica, or intermitting 
pulse, &c., and threaten from tiieir violence sudden dtuth, at the next attack; the 
bark is to be administered in great quantities, and frequently repeated, heg-inning 
as soon as the fever abates: 8 or 10 g-rs. of the sulphate of quinine, every two or 
three hours, in desperate cases, may he attempted: In the mean time, the l)o\vel3 
should be kept freely open, by purgatives of calomel and jalap, particularly 
where there is pain in the head or breast; bleeding- is necessary, especially in the 
apoplectic, comatose, and rheumatic forms, if the pulse be full and frequent : it must, 
however, be used cautiously and in small quantities from its effect in reducing- the 
system and favouring- the ag-uish disposition. Diarrhoea, where it is excessive, 
should be restrained from the dang-er of debility: 'I'he means, also recommended, 
to alleviate other dang'erous local symptoms, should, also, be practised according 
to circumstances.* 

IX. When the case has been neg-lected, or the patient injured by vomits, by 
excessive exercise used to prevent the fit; where the pai-oxysms are protracted, 
violent, and run into each other, or are attended with coma; these symptoms are 
perplexing-, and are to be palliated by purg-ing with Epsom sahs, combined with 
the bark;\an oz. of the former to ^ss. of the latter, divided into four portions, and 
one to be taken every two hours: 'J'he fit becomes milder, an intermission suc- 
ceeds, and the bark alone, then, will complete the cure: If syncope and dissolving 
sweats be present, or excessive weakness, and the patient cannot bear purges; 
cordials, of which wine is the best, may be given, with six or eight drams of the 
bark in 10 or 12 hours: In these cases, large doses must be prescribed, otherwise, 
the next fit may be fatal :f Torti advises an oz. to be given at a dose; ten or twelve 
grs. of the sulphate of quinine may be taken evei-y two or three hours. 

X. When the pulse is small and hard, or obscure, without expansion, or where 
a vermicular motion is observed, in the state of the artery, with a constricted skin, 
or a clammy moisture, on the surface, it has been found useful, to premise blisters 
to the back of the head and neck; the bark, without them, does no good.t C. 

But there are certain states of the constitution, which are found 
to interfere with the exhibition of bark in any form, and to coun- 
teract any good eflfects from it. The principal of these are, inflam- 
matory diathesis prevailing in the system, disorders in the primae 
viae, obstructions of the liver and spleen, and the presence of other 
diseases. Hence arises the necessity of giving purgatives, or saline 
or antimonial medicines, or alteratives, particularly mercurials, 
either previous to, or combined with bark, according to the 
circumstances of the case. 

To be more particular, I. An inflammatory diathesis is evinced by a small hard 
and frequent pulse, flushed face, difficulty of breathing, pains in any part of the 
body, general fever, sizy blood, pain increased on pressure of certain parts, dry skin, 
yellow tongue: purges and venesection then succeed completely: The early use 
of the baric in these cases, produces stricture of the chest, an increase of fever, 
black stools; and if continued, cachexy, suppuration of the liver, dropsy, and even 
melancholy, are its consequences :§ also stupor, diarrhoea, continued fever, dysen- 
tery, spasms and death. 

The debilitating eflfects of heat, old age, and previous evacuations, often will 
determine the propriety of not drawing blood, though the pulse and other symp- 
toms indicate it: the character of the prevailing epidemic will also afUbrd some 
insight into its propriety; if bleeding is well borne in other diseases, it will also 
be in this. 

II. In a deranged state of the liver, evinced by a pale or yellowish cast of counte- 
nance, hard and tumid belly; the neutral salts continued daily for some time are 



* Alibert. f Cleghorn, p. 210-11. 

t A treatise on the Fever of Jamaica, p. 210. Phil. 1795. § Scnac, 



150 INTERMITTENT AND REMITTENT FEVERS. 

useful; and if the cachectic disposition is of longer continuance, calomel, jalap, 
rhubarb, g-ambog-e or scammony to purge daily, will be necessary: A slight saliva- 
tion may be tried; if that is not successful, a gr. of the extract of cicuta has a good 
effect. Pringle found antimonial emetics useful in this form. When the belly 
becomes soft the bark may be administered.* 

III. Dropsy. Purgatives are then to be relied on: However, as Sydenham 
remarks, the intermittent must be cured, before they can be administered, as the 
debility produced by the purgatives confirms the ague, without relieving the 
dropsy. The bark, therefore, must be given, combined with light diuretics, accord- 
ing to the case: nitre, in the dose of a scruple, given in an infusion of juniper 
hemes, or horseradish, will assist the cure: frictions upwards, and in the morning 
only, if the legs only are swelled, will be proper. 

Purging succeeded with Pringle, only when united with the salt of tartar; the 
bowels were opened by half a dram of the pillul. ex colocynthid. cum aloe, given 
once in four or five days; forty grains of salt of tartar were dissolved in about ten 
ounces of wormwood tea, to which were added about two ounces of Holland gin; 
and the mixture was taken at three draughts, and repeated daily; in the decline 
of the disease, some common chalybeate was given: garlic, or mustard seed, taken 
internally, promoted the effect: horse-radish, also black-pepper, are sometimes 
useful. The bark should be given after the water is removed to complete the cure : 
antimonial vomits Pringle also found to succeed, in removing the dropsy: the 
following prescription he also recommends highly. R. Flor. Chamom. ^ss. aq. pur. 
bull. ^viii. macera per dimidium horse et colatur. admisce spirit, vin. gall. ^ii. 
salis absinthii ^i. Dose — ^ii. three or four times a da)^ 

Exercise, as violent as the patient can properly bear; frictions; warm clothing, 
and cantharides, as a diuretic, with peruvian bark, are also valuable. f 

IV. If there be pain in the head during the intermission, local bleeding often 
relieves it and prepares for the bark. Cleghorn recommends in this case, the 
pediluvium, and a cataplasm of horseradish to the soles of the feet. When this 
pain proceeds from the stomach, emetics will relieve it. 

V. Excessive sweats. Venesection often relieves this symptom, when the patient 
is still strong: If the signs of obstructed liver be present, purges succeed.^ If 
they proceed, however, ti-om excessive debility; tonics, and gentle laxatives with 
exercise are proper. 

VI. Tympanites. Pringle tells us, that sometimes the belly swells suddenly, 
after the improper use of the bark, or of opium in dysentery, from the distension 
of the colon, by air. He advises, if there be fever, to bleed; also to purge with 
rhubarb, and give the following saline mixture: R. Sal. absinth. ^\. clix. vitriol, 
acid. ^ii. vel quod satis sit saturand; aq. purx 5vi. aq. cinnamom. simpl. ^i. syrup. 
e corticib. aurant. 5ss. m. Dose §ii. five or six times a day: If there be no fever, 
the rhubarb with the aromatic electuary, drinking at the same chamomile tea; 
every night at bed time, 15 grains of rhubarb were given till tlte tumour disap- 
peared, adding also steel, ginger, and chamomile flowers, if the bowels appeared 
to be debilitated: all strong purgatives, without laxatives, he found to be hurtful.§ 

VII. Sometimes the paroxysm does not complete its course; thus, we have fever 
without sweat; then the bark does no good, when given in the interval alone, but, 
if during the fever, the patient drink largely of warm tea, and frictions of the skin 
be used, towards its conclusion, with warm flannels, the sweat breaks out, and he 
is relieved: If the chill is excessively violent, and is follov/ed by no fever, then 
opiates ought to be given with the bark in the intervals. 

VIII. Sydenham tells us, that hectic often succeeds intermittents in children; 
and is distinguished by a swelled and hard belly, a cough, and other consumptive 
symptoms, with some complication of the rickets: Purgatives on every other, 
or on every third day, producing at each time five or six motions a day, should 
be continued for nine days; (we suppose till the morbid matters are thoroughly 
evacuated.) In continuing the purgative, after the first thorough cleansing as 



* Senac. 

f A Treatise on the Fever of Jamaica, p. 219. Phil. 1795. 

i Med. Recorder, vol. vi. j). 538. 

§ Rush's Pringle, p. 191. 1810. 



INTERMITTENT AND REMITTENT FEVERS. 151 

above advised, it is necessary to recollect, that violent purging debilitates and 
keeps up the ague; it is, therefore, proper to administer the purgative once a 
week, for two or three months, and give a quieting draught, in the evening, after 
the operation, to prevent the return of the fit; which sometimes happens from the 
mildest disturbance the cathartics may produce:* Sydenham remarks with regard 
to intermittents in children, that the fit hardly ever ceases in them, till the belly, 
near the spleen, begins to swell and grow hard; this swelling with that of the legs, 
is an almost certain sign of the disappearance of the disease in children. 

IX. Sydenham also mentions a pain and inflammation of the tonsils, after con- 
tinued or intermittent fevers, attended at first by difliculty of deglutition, suc- 
ceeded by hoarseness, hollow eyes, and hippocratic face, portendmg imminent 
death; they are produced by profuse evacuations in patients worn out by the 
violence and long continuance of the disease. 

X. The same author also mentions madness as a symptom, which follows long 
continued ague: evacuations long protracted change it into confirmed idiocy: it 
is cured only by a slender but restorative diet, by stimulants; confinement to the 
chamber and lying much in bed; when the disease abates in the course of a few 
weeks, the stimulants are to be omitted for a few days, continuing the diet as before 
directed; again repeating the cordials in a few days, and persistnig in them, for a 
short interval, till the recovery of the patient; this plan cures madness in cold and 
weak constitutions, when an ague has not preceded.f 

XI. Sometimes diabetes follows the ague in aged people, when the disease has 
been of long standing, the patient much debilitated by bleeding and purging; to 
increase the strength is the plan here; for this purpose, tonics, as the bark, 
wine and animal food, with a most rigid abstinence from vegetables are proper. 

XII. Sometimes the disease is still incurable by any of the ordinary remedies; 
Senac succeeded in these cases, by keeping the patient for three or four days on 
water alone: Warm water, of which he gave six or eight pounds a day, was 
preferred: This plan has succeeded in Lancaster county in this state, in cases, 
incurable by other means: The visceral indurations, the brown tongue, and sallow 
skin, soon disappeared; at the end of four days they were allowed barley water for 
their diet, and as much burdock tea as they could drink; then by the use of gentle 
tonics they completely recovered. An excited pulse after taking exercise, though 
moderate; the appearance of the same symptom on certain changes of the wea- 
ther or irregularities of diet indicate the above plan: A course of gentle purging 
by mineral waters with a moderate diet of chicken, beef and mutton, the farinacea 
and change of air succeed, after all plans have been used^in vain. When they all 
fail, Senac advises the patient to be left to nature, keeping the bowels moderately 
open, and using as above digestible food. 

XIII. When the disease proceeds from a rheumatic, venereal, gouty, or scorbutic 
diathesis, which often assume the intermittent form, then each of these are to be 
treated by their appropriate remedies:^ If there be a local weakness; as pain from 
a carious tooth, it will often assume the intermittent form, and the bark will in many 
instances cure it; yet if the affection be considerable, the removal of it will be 
necessary, as the irritation of the inflamed nerve debilitates the general system, 
as the intermittent also increases the local disease: and so of other irritations. C. 

SUBSTITUTES FOR THE BARK. 

Various substitutes for the cinchona bark, native and foreign, 
have been introduced into the Materia Medica. They all belong 
to the class of bitters and astringents; and though attempts have 
been made to establish chemical differences between them and the 
cinchona, yet these have thrown no light on the cause of the 
acknowledged superiority of the latter. Among the best substitutes 
for the cinchona bark may be reckoned those of the cusparia, of 



* Sydenham, Rush's Ed. page 45, 6, 7. f Ibid. p. 49, 50. 

t Storck, Ann. Med. p. 174. 



152 INTERmTTENT AND REMITTENT FEVERS. 

diflferent species of salix and quassia, and the roots of the acorus cala- 
mus, bistort, and rhatany. 

The species of willow, which has been found particularly useful is the Salix 
latifolia or caprea, (broad leafed willow bark.) It is given in the dose of an oz. 
and a half of the dried or pounded bark to a pint and a half of boihng water. The 
dose is half a g-ill five or six times a day. 

Some of our native willows are recommended, particularly the alba, pentandra, 
and latifolia above mentioned. The barks of some of our oaks are also mentioned 
favourably — of the prunus Yirginiana, the sassafi-as (Lanrus sassafras) the persim- 
mon (Diospyrus Virg-iniana) the dog-wood, (Cornus Florida, and Sericea,) from 
vvhicli Mr. Carpenter has procured a salt, the sulphate of cornine, which has been 
used with success by Ur. Morton of this city; the dose of the cornine is three or 
four grains every two hours. 

The Magnolia grandiflora, the liriodendron tulipifera, populus tremula have also 
been used in this country for the cure of intermittents: The aristolochia sipho, 
and a. serpentaria, are also recommended, as valuable tonics. They may be used 
in the dose and form above prescribed, for preparing the salix latifolia. The 
Eupatorium perfoliatum is recommended by Dr. Hosack and Anderson as valuable. 

The calamus has been found valuable united with equal parts of bistort, a little 
ginger,* and given in the same dose as above. 

The rhatany is recommended in the dose of twenty grains of the powder, or in 
the form of extract or decoction.t It does not, however, answer the expecta- 
tions of its best friends. Charcoal has also been recommended in the dose of a 
scruple or half a dram three or four times a day; It often succeeds, but, without 
purgatives, it pi'oduces dangerous concretions in the bowels.^: Cobweb, in the 
dose of two or three grains thrice a day succeeds also. 

The cinchona carribea, the St. Lucia, and Tellicheri bark are also highly spoken 
of. The quassia is given in the quantity of (^ii. to ^x. of water.) ^ii. every two hours 
during the intermission: The gentian, cascarilla, or serpentaria may betaken in 
the same way: The faba Sti. Ignatii. one and a half gr. infused in ^ii. of water, and 
given morning and night, Lind tells us, has succeeded. It is, however, uncertain. 
The oxide of zinc in the dose of two grs. four times a day has also been used with 
success: The sulphate of copper in one-fourth to half a grain, at the same interval; 
and the cuprum ammoniatum, in the same dose, have alio in some cases done 
good. The rubigo ferri, the sulphate and steel filings are also given with success 
in cases of old standing: all these medicines may be combined with the Peruvian 
bark,§ and thus increase its efficacy. The cold bath also succeeds completely in 
arresting the ague if taken twice a day during the intervals. C. 

Of the mineral substances employed in the cure of agues, the 
most powerful is undoubtedly arsenic, the efficacy of which has 
been ascertained by the most ample experience. It is best given 
in the form of the liquor arsenicalis, and in the dose of five drops, 
gradually augmented. After a certain length of time, sometimes, 
indeed, from the very first, it will produce nausea and vomiting, 
when its exhibition must be suspended, and a few grains of rhubarb 
given. Under proper management, arsenic will be found, next to 
bark, the most generally useful of all the medicines which have 
been recommended in the treatment of agues; but its administra- 
tion requires the same cautions as that of bark. 

It produces, also, dropsical swellings, palsy of the extremities, and even death. 
It should, therefore, never be continued longer than two weeks at a time, and its 
dose should be diminished or suspended, when the system is highly sensible to its 
action. It may be united with the bai-k taken in infusion, decoction or powder. 



• Thomas' Practice, p. 14. f Ibid. 

+ Medical Recorder, p. 339, for 1825. § Thomas' Practice, p. 17. 



INTERMITTENT AND REmTTENT FEVERS. 153 

Though the author mentions, that it is subject to the same rules in administering 
it as the bark; yet, in moderate inflammatory cases and during the fit, it may be 
given when the bark cannot, and without regard to cough, pain, or other local 
aflnections. 

The best mineral substitute for it is the sulphate of zinc, which 
is largely employed in the fenny counties of England. It is given 
in doses of one or two grains, three times a day, and in conjunction 
with a small proportion of opium, has proved eminently serviceable. 

The prussiate of iron, as recommended by Dr. ZollIckoflTer in the dose of ten 
grains, thrice a day, has been praised by Dr. Hosack; with others it has failed. 

Change of air, from land to sea, or to mountainous and dry situations, with the 
bark every morning and evening, are also most effectual plans. If the attack 
should come on, then it will be necessary to be more moderate in the use of the 
necessary evacuations, which are to be directed according to the rules above laid 
down, according as there is general fever, affections of the liver, stomach or bowels. 

OF THE collateral' MEANS TO BE USED DURING THE INTERVAL. 

I. With regard to the diet. It should be of such a kind as to give strength in 
the highest degree, and in the easiest manner. Or, in other words, it should be 
the most nourishing, least irritating, and most digestible: The farinacea; as rice, 
sago, panada, barley, boiled with raisins or figs; also apricots, peaches, prunes, 
apples, will form a good diet, during the remissions, taking them at a time suffi- 
ciently remote to complete the digestion, before the fit comes on, so as to gain the 
greatest strength.* These kinds of food will be most proper, where the paroxysm 
has been inflammatory; in cases where the patient is much debilitated, and a 
more tonic plan is required, mutton, beef, and fowls will be the most proper: the 
articles first mentioned, rice, &c. should be boiled. Broiling is the best mode of 
preparing animal food; and if any drink is thought proper, from the debility of the 
patient, or from his previous habits, beer, porter, or port wine, with water, will 
be found to be best: lamb and veal are more indigestible than beef and mutton: 
wild fowl is proper; fish not so, from their difficulty of solution, more particularly 
those which become adhesive on boihng; or others which are too firm: oily and 
acescent substances are most difficult of digestion; the flesh of old animals more 
easy than that of young; vegetable substances more difficult than animal; which, 
however, are more irritating: It is, therefore, necessary to look to the state of the 
fever, and to the powers of the stomach in prescribing for it; selecting those 
articles, which furnish the greatest strength, and expend the least in assimilating 
them: 

If the stomach be w^eak, animal food, biscuit, or stale bread will be most proper; 
fresh vegetables, smoked and baked meats, pastry, cucumbers, melons, soup, 
gravies, butter, should be avoided; the drink should be taken of a moderate tem- 
perature; as dyspepsia has been produced by taking it excessively cold:f 

If the patient has been accustomed to live generously, low diet will increase the 
tendency to a return of the fits: 

The use of proper food is essential, because acidity, and disagreeable sickness, 
indigestion, want of appetite, imperfect remissions, pain in the forehead, furred 
tongue are the results of the accumulations, which take place from imprudence 
in this respect, in the stomach and intestines, and which can only be removed by 
strong emetics or purges, t 

II. Mr and exercise. Every means of increasing the strength should be had 
recourse to, when the patient is entirely clear of fever: pure country air, in an 
elevated situation, remote from any miasmatic, or other source of impurity, should 
be sought: gentle exercise at first; as walking, also friction with the flesh brush, 
and, when the intermissions become more perfect, exercise on horseback will be 
advisable: any violent exercise will be improper, till the fits are completely 



* See Fordyce. f See Phihp, vol. i. p, 123. 

% Fordyce, p. 47. 1794. 
20 



154 INTERMITTENT AND REMITTENT FEVERS. 

checked: and as the patient convalesces, tlie adoption of the more violent kinds 
should be gradual ; as walking- and saihng-; riding- g-ently in a carriag-e, then the 
use of dumb bells, a trotting- horse, kc, as he becomes strong-er, will gradually 
confirm the cure.* 

The exercise of the mind, also, in those modes which are most congenial to it; 
as in business, taking care not to fatigue it: amusing reading and society, when 
there is no fever or irritation in the interval, will be proper. 

Retire early,f at the same time take care not to lie long in bed; I have seen a 
lady so nervous from great indulgence in this respect, that if she laid in bed 
beyond a certain hour, her debility became so great that fainting on any slight 
exertion was the result. The early period of the disease, the strength of the 
patient, whether debilitated by previous sickness; his age; his former habits with 
regard to exercise, must regulate its degree: It must, however, be recollected, 
that even to the latest period of life, the inflammatory diathesis sometimes pre- 
vails; a spare diet and blood-letting is, therefore, often proper, even in the case 
of persons fur advanced in life; the spring always renders the habit more inflamma- 
tory, and therefore requires depletion; whereas, in the autumn, stimulation 
becomes necessary, from the abstraction of the heat of the summer, which leaves 
the body in a less irritable state, t 

In order to prevent a return of the ague, it is necessary to continue the bark for 
some time, two weeks or more, then substituting for five or six days some other 
tonic, and afterwards again to resume it; rain, cold, nig-ht and morning air, 
marshy situations; the hot sun, and all excesses in diet, or any thing which may 
debihtate, must be avoided. 



Remittent fever arises, as I have stated, like the intermittent, 
from marsh exhalations. It is a type of fever very frequent in hot 
climates, where it occasionally occurs under a highly aggravated 
form. Its symptoms vary with the nature of the climate, season, 
the constitution of the patient, and many local circumstances, so 
that it is difficult to give any precise detail of them. They bear 
a general resemblance to those of intermittent fever; but other 
symptoms, such as we formerly mentioned as occasionally occur- 
ring in the course of continued fever, are met with also in the 
remittent, and materially affect the character of the disease, the 
prognosis, and the method of cure. Of these, the most important 
are those which indicate severe gashnc derangement; and this 
combination of remitting fever from paludal exhalation, with dis- 
turbance in the functions of the upper abdominal viscera, the con- 
sequences of atmospheric heat, constitutes that formidable disease 
known by the name of the bilious remittent of hot climates. 

The treatment of this, and of all the other varieties of remittent 
fever, is to be regulated, partly by those principles which have 
been laid down as applica])le to intermittents, and partly also by a 
consideration of those which guide us in continued fever. 

MODE OF PREVENTION OF THESE DISEASES. 

M'ith regard to the prevention of intermittent and remittent fevers, experience 
recommends the following plans; tlie bark, nourishing and stimulating drinks, as 



• See Philip and Fordyce. f Philip. 

1 Philip, p. 127, 8. 



INTERMITTENT AND REMITTENT FEVERS. 155 

mvitton, beef, and fowls, with porter, wine, &C.5 avoiding drinking punch, lemon- 
ade, spirits, or simple water in g-reat quantities, as they debilitate. Chamomile, 
quassia, or g-entian tea, are good drinks. 

Avoid the morning, evening, and night air, the hot sun, great abstinence, 
intemperance in eating and drinking, improper food; as acids, rich sauces, 
pies, high seasoning in excess; at the same time, if the stomach has been accus- 
tomed to it, it is necessary not to abstain entirely from these articles, as the strength 
must be at all times kept to its highest degree; choose the upper story for a 
residence; shut up the windows of the side of the house, fronting the marsh from 
which the exhalations come. 

Do not visit an infected district, after living for some time in a pure air. 

If the marsh is small, drain it, fill it up, or scatter lime over its surface; the 
inundation of a marsh has completely arrested the intermitting fevers produced by 
it. The removal, burial, or destruction, by fire or water, of all putrid matters, have 
done so likewise. Marshes are rendered healthy by timber growing upon them, 
thus preventing the action of the sun; trees condense, it is probable, the miasmata 
upon their leaves, the temperature of which is always lower than that of the 
surrounding air, in the excessive heats of summer, when miasmata are produced 
in the greatest quantities: In this way, trees near houses protect the inhabitants 
from their effects, and a wood between a marsh and an encampment is said to 
prevent the ague in soldiers. 

Ventilation, thorough cleansing of houses, warehouses, ships, hospitals, and all 
places where there may be filth, are necessary: the streets of a city should be kept 
perfectly dry, by causing the water to run off by sewers below them, and burning 
or carrying away all vegetable matter, and other refuse of kitchens. 



( 156 ) 



CHAPTER VIII. 



OF THE YELLOW FEVER. 



Coniroversy on this subject — Varieties of Fever in the West Indies 
— Symptoms of the Epidemic Yellow Fever — Its Analogy to 
Typhus — Treatment of the Disease — JVotice of the principal con- 
troverted Points in the History of the Yellow Fever — Question of 
foreign Origin — Of Propagation hy Contagion — Of Exemption 
from a second Attack. 

Although we presume, that in the observations which have 
been already made, we have explained the most important of those 
general principles which are involved in the pathology of fever, 
and though the discussion might therefore be expected to terminate 
here, still it may be found advisable to pay some particular atten- 
tion to the subject of yellow fever. It is one which has excited a 
great deal of interest in this and other countries, during the last 
thirty years. It has given rise to the most remarkable diflferences 
of opinion among persons who are, to all appearance, equally 
qualified to form a correct judgment regarding it; nor is the con- 
troversy yet brought to a conclusion. Little doubt can remain, 
that these singular differences of opinion have arisen from the want 
of correct views of the pathology of fever; and it surely cannot be 
a useless task to attempt to elucidate a subject, confessedly so ob- 
scure, by applying the doctrines which have been already laid 
down, to an explanation of the principal points in dispute.* 

The yellow fever is a term which has been applied to express a 
particular form of febrile disease, which has been observed to pre- 
vail in the West Indies, along the shores of North America, par- 
ticularly at New York and Philadelphia, and more lately in the 
southern parts of Spain. It has received various names. By some 
it has been called the Maladie de Slam; by others the Bulam 
Fever. Though justly accounted among the endemics, of hot 



* This task has been rendered comparatively easy by the recent labours of Sir 
Gilbert Blane, who, in his Treatise entitled *' Elements of Medical Log-ick," has 
j^iven a very luminous view of the yellow fever question which almost precludes 
the possibility of future ambig^uity. 



OF THE YELLOW FEVER. 157 

countries, it has yet principally excited attention from having pre- 
vailed epidemically in those regions, and been productive of very 
great mortality in particular seasons. The endemic fevers of the 
West Indies, like those of other countries, are either such as arise 
from marsh effluvia, or from what we have called common causes, 
cold, alternations of atmospheric temperature, or insolation; — that 
is to say, they are either intermittent, remittent, or continued. In 
almost all the controversial writings on the yellow fever, these 
different forms of febrile disease have been confounded together; 
and it has accordingly been, from want of precision in the naming 
and classing these fevers, that several of the disputed points have 
originally sprung. But there is a second general cause to which 
the controversy may be referred, whose influence is even yet more 
extensive than that of error in the classification of fevers; — I mean, 
a want of correct knowledge of the general laws of contagion. 
The consequence of this has been, that the analogies and distinc- 
tions of epidemic and endemic diseases have been overlooked or 
misrepresented. It is hopeless to attempt to reconcile the dis- 
cordant opinions of authors on the yellow fever, if these funda- 
mental doctrines are still made matters of dispute. 

As the author has probably never seen the disease, and has drawn his opinions 
and reasoning- from hig-h authorities, we can only notice some of the leading- items 
he has copied. We propose to examine some of the most prominent features of 
doctrines by the test of experience and fact rather than yield them throug-h the 
medium of speculation. We admit that Sir Gilbert Blane is the ablest advocate of 
the doctrine of contag-ion who has publicly appeared^ but after the most scrutiniz- 
ing- examination of his reasoning we are oblig-ed to conclude, that his arg-uments 
are inconclusive. To this broad assertion we may (however presumptuous it may 
appear to some) state that we have elsewhere refuted his reasoning- by anticipa- 
tion. The remark of the author, that there exists "a remarkable difference of opi- 
nion among those equally qualified to judge,-" is very far from being- the result of a 
g-eneral understanding among professional men. Of those whose clinical observa- 
tions have been the basis of their creed, not one in forty inclines to the doctrine of 
contagion in our country, and as to our opinion of such as have not seen the dis- 
ease, it merits no more respect, than that of the naturalist who should undertake 
to describe the productions of a region he never saw. We agree with the author 
moreover that " a want of correct views of pathology," is one of the sources of dif- 
ference of opinion as well as of much error, and on this admission will endeavour 
to show the fallacy of the opinions adopted by the opposition. The appellations 
bestowed on the disease, are sufficiently expressive of the defective state of its 
pathology. The epithet yellow is only incidental. It is to be observed only in 
the worst cases, or in those that have been neglected or improperly treated. If 
the proper system of depletion be opportunely and sufficiently applied, this ap- 
pearance is not to be seen. Synochus Icieroides is a name still more unfortunate, 
because it presumes to fix the degree of fever, a power which no nosological title 
can confer. It may measure the type and detail the symptoms, but cannot tell the 
quantity of disease: the fever consists of all degrees (according to the condition of 
the nerves of the subject) from the most ferocious synocha to typhus gravior, and 
are successfully treated by the remedies for those states, thougii generally by 
evacuations. AH the names given to the disease are founded on some uncertain 
and precarious accident. The existence of the disease at Siam or Bulam only 
proves it the product of warm climates, but does not prove it contagious. It has 
been called La fievre matelotte, because it has so often appeared on ship board, 
but this does not establish that it is contagious. Almost every symptom of the 
fever has given it a name according to the fancy of some one who has seen it. It 
has been called by the Spaniards vomito Frieio,'the black vomit, although it is only 



158 OF THE YELLOW FEVEK. 

an accidental concomitant. It is clear it cannot be pathognomonic because free 
and early evacuations g-enerally obviate such a termination; and for another reason, 
because many die of yellow fever without this symptom, with and without medical 
treatment. The affection of the brain kills some, the condition of the liver some, 
and the inflammation of the duodenum and consequent sphacelus others. 

The doctrine of contagion of plague, typhus and yellow fever appear to arise 
from prejudice. It is strange that the most illiterate men in the West India islands, 
where yellow fever has prevailed since they were visited by Europeans, will laugh 
at such an opinion, while philosophers are devising all the means that sophistry 
can invent to prove what the universal experience of mankind contradicts. Hun- 
dreds of persons ill of yellow fever are received into our hospitals during the 
existence of all our epidemics, and there has been no interruption of the intercourse 
between them and their friends, who have invariably visited them with impunity. 
Neither nurses or visitors have contracted the disease. P. 

The yellow fever is not reproduced like the small pox and measles by a matter 
generated by the sick; Because inoculation with the saliva, with the serum of 
the blood, and the black matter from the stomach does not produce it; this fever 
in hospitals in the country, where physicians and others breathe the air, touch 
and even handle the sick, is not communicated; mothers ill with the disease sleepr 
ing with their children, also parents, and friends under the same circumstances do 
not in a country air communicate it: If, however, the disease be protracted, till it 
assumes the typhous form, the excretions and perspiration will reproduce that 
form, as in all other cases of fever; the disease will, then, be typhus and not the 
yellow fever; as the yellow fever ends rapidly, either in death or recovery, typhous 
symptoms hardly ever appear; on this account, the disease seldom becomes 
infectious. 

Heat, moisture and putrefaction from any cause may produce the yellow fever; 
on this account, the clothes and excretions of the sick, in close and unventilated 
places sometimes, though very rarely reproduce it: the excretions of the well 
under the same circumstances would have had the same effect, as there is no 
peculiar contagious matter generated in this fever: From the shortness of its dura- 
tion, typhous symptoms more seldom appear in it than in common remittent fever; 
it .should, therefore, be considered as less likely to be contagious than almost any 
other form of fever. Putrefaction is the cause of yellow fever: 1. Because this 
fever increases and decUnes with the summer, the season which produces putre- 
faction. 2. The same causes; as, frost; intense dry heat; high winds from the 
north; lasting, heavy inundating rains; the destruction of putrefying materials by 
fire, or water, which arrest putrefaction, also arrest the yellow lever: The reader 
will find both sides of tliis subject fully and ably discussed in the essays of Dr. 
Hosack, and Dr. Rush. 

Most of the genuine febrile diseases of hot climates appear to 
have a bilious tendency. Both the inflammatory and the inter- 
mittent and remittent endemics of those countries, are frequently 
accompanied with a yellow colour of the sldn, and other symptoms 
supposed to denote that the functions of the liver are materially 
disturbed. Into the symptoms and treatment of these forms of 
disease, however, it is not my intention now to enter. They are 
noticed only, in order to compare them with the genuine yellow 
fever, such as that which raged in the West India Islands and at 
Philadelphia in 1793; at Cadiz in 1800; at Malaga in 1803; at 
Gibraltar in 1804 and 1813, and at Ascension Island in 1823. As 
this particular form of fever has been observed in all these situa- 
tions to exhibit very much of the same defined character, and as it 
presents some peculiarities which may distinguish it from other 
epidemic fevers, I shall give a short account of its symptoms and 
progress, of the appearances found on dissection, and of tlie most 
approved system of treatment. It must be remembered that the 



OP THE YELLOW FEVER. 159 

same kind of fever is occasionally met with as an endemic of the 
West Indies; but to avoid ambiguity, I shall here direct my atten- 
tion exclusively to the epidemic disease; the characters of which 
are strongly marked. 

The attack of yellow fever is ushered in, in the usual way, by 
languor and rigors. There is sometimes a peculiar dejection of 
countenance observed, with a remarkable aversion to the least 
motion; at other times there is an appearance of inebriation. The 
face is flushed, but the most prominent of the early symptoms of 
the disease is headach, of a very peculiar kind. It is exceedingly 
severe, and referred to the forehead and bottom of the orbits. The 
eyes appear dull, glassy, suffused, and protruded. The tongue is 
at first furred and moist, and trembling, but by degrees it becomes 
dry and black, or sometimes of a fiery red colour. The heat of 
skin is but little increased. The patient sometimes lies in an 
almost insensible state, but extreme restlessness has also been 
noticed. 

To this succeeds the second striking feature in the symptoms of 
the disease, great irritability of the stomach. The matter rejected 
is very seldom bilious, or if so at first, it speedily loses that character. 
For the most part it is slimy and tasteless, and adheres in small 
flakes to the sides of the containing vessel. As the disease ad- 
vances, it assumes a dark colour, and comes to have the appearance 
of coffee-grounds. This is the black vomit, which may be con- 
sidered the characteristic feature of this disease, as much as buboes 
and carbuncles are of the plague. The dej ection^ have a tarry 
appearance. There is often noticed a suppression of urine, which 
like the black vomit, is a fatal symptom.* Hiccup, haemorrhagies, 

* The following is a description of its most violent form. 

The attack of this disease is g-enerally sudden and without chill; there is violent 
pain in the head, back, and limbs; there is great prostration; almost immediately 
succeeded by vomiting", red eye, suffused and tumid face; the parts about the fauces 
and throat are so likewise; the patient speaks thick, as if his tongue was too big* for 
his mouth, very much like an intoxicated man; the skin is arid; the heat burning-, 
pain in the head, acute, and fixed above the orbit of each eye, with a sense of 
weig-ht in the whole head and difficulty of speaking-: There is a fixed burning- heat 
at the pit of the stomach, with anxiety and restlessness, continual and distressing- 
vomiting-, and loss of appetite: Large drops of sweat hang on tlie face; the tong-ue 
is g-enerally moist and morbidly clean, more red than in health with a peculiar 
expression of face. 

Hig-h and fierce deUrium g-enerally comes on about the second day; the patient 
requires two or three persons to hold him in bed; the eyes seem to burst from 
their sockets; rolling- about with a fierce expression: death closes the scene on the 
third or fifth day; the fever subsiding and the senses returning some little time 
before; the eye now becomes glassy and is no longer red, the skin moist and cool; 
the vomiting ceases; the pulse full; syncope or convulsions, are the last and fatal 
symptoms; the former, particularly, in the most violent forms.f 

When it attacks dehcate persons, the fever is not so high; there is often no 
delirium, the vomiting is also more mild; the matter thrown up undergoes a 
gradual change; at first the remains of the last meal, then mucus streaked with 

t This history is taken from Fowle, a writer in the Leeward Islands, and exhibits the disease in its 
»vorst and most common form there : In the northern latitudes its intensity abates. 



160 OF THE YELLOW TEVER. 

and petechiae have been observed in some cases, even from an early 
period. 

I have retained to the last the mention of that symptom which 
gives name to the disease — yellowness of the skin, but it is not of 
that importance which might have been anticipated. Many cases 
indeed run through their whole course without exhibiting it; but 
when it appears early, or when the skin assumes a leaden or livid 
cast, it is to be considered an unfavourable symptom. A few other 
peculiarities in the disease are all that remain to be noticed. The 
yellow fever is occasionally attended v/ith an ulcerated state of the 
throat. A fatal termination has often happened in the most unex- 
pected manner; a very singular remission of all the symptoms 
taking place about sixty hours from the first attack, and raising 
hopes which are soon to be disappointed. Death is sometimes 
preceded by a degree of low muttering delirium; at other times 
the patient sinks exhausted, but with the intellect quite unim- 
paired. 

Signs of moderate danger: A chill accompanying the disease; the longer its 
duration, the more favourable is it; the recurrence of chills preceding the fever 
every day, or twice a day favourable; a coldness of the whole body, without chills; 
coldness, with a profuse sweat; cold feet and hands, with febrile heat; a profuse 
sweat without a chilly fit, less favourable than a regular chilly fit, indicating, how- 
ever, less danger, than their total absence during tiie course of the fever.* 

A puking of bile, on the first day, favourable; of black bile, not unfavourable; also 
a soft, moist skin, at the beginning of the fever; increase of pain after bleeding; 
pain in the head, translated from external to internal parts, or to the back; a sore 
mouth; a moist, white, yellow tongue; an early disposition to spit freely; blood sizy, 
after other appearances flfjjiprbid action in the blood vessels; great sensibility in 
the sense of touch towards the close of the fever; and acute pain in the back or 
limbs, f 

The following are signs of great danger and unfavourable issue; the fever coming 
on after a fit of anger, terror, excess of venery, or of strong drink; the first fit 
without a chill, or any premonitory sign; a coldness over the body for two or three 
days, and without chills; sleepiness on the first and second days; uncommon pale- 
ness of the face, not induced by venesection; constant vomiting without discharge 
of bile; obstinate costiveness, or a discharge of natural white stools; quick watery 
stools after taking drink; diarrhoea towards the close of the fever; a suppression 
of ui'ine, most alarming when without pain; a discharge of black coloured urine; 
a cold, dry, smooth, shining skin; a yellow face on the first or second day; no pain, 
or a sudden cessation of it; a disposition to faint upon every little motion; a watery, 
glassy, or brilliant eye; a red eye on the fourth day of the disease, more alarming 
after being yellow; imperfect vision, and blindness in the close of the disease, a 
preternatural appetite in the last stage; a slow, intermitting, and shattered pulse; 
great restlessness; delirium, and lasting coma; black vomit, like coftee-grounds, 
after the fourth day; a smooth red tongue, covered with a lead coloured crust; 
insensibility to common occurrences; uncommon serenity of mind, and placid 
countenance ;i: all these signs, however, arc indecisive, from the Protean character 
of the disease. 



blood, which comes from the fauces: The contents of the stomach are streaked 
with brown; then comes a blackish fluid like gi-ounds of coffee, thrown up without ^^ 
difficulty, and without smell or taste: Excepting bleeding from the nose, this is the If 
most fatal symptom: Hiccup and diarrhoea are also dangerous.^ 

* Kush, iv. 55, 56. f Ibid. iv. 57. 1809. ^ Ibid. 55—61. 

§ Fowle, Practical Treatise on the Yellow fever in the Leeward Islands. Lond. 1 800. 



OF THE YELLOW FEVER. 161 

The usual duration of the yellow fever is from five to seven 
days. If the patient passes the sixth day without the occurrence 
of black vomit, or suppression of urine, his chance of recovery is 
much increased, but even then symptoms like those of common 
typhus occasionally supervene, and prove fatal. Relapses in this 
fever are very rare. 

Upon dissection, very few appearances present themselves which 
can be considered as throwing light on the pathology of the disease. 
The body has been observed speedily to become livid. Yellowness 
of the skin has sometimes been first noticed to occur after death. 
A state of turgescence of the cerebral veins has been described, and 
occasionally there has been observed a peculiar redness of the inner 
coat of the stomach. 

The gall-bladder is generally found distended with dark and 
viscid bile. The structure of the liver is not found to be altered. 
It sometimes assumes an ash colour. 

Dr. Cart\rrig-ht found tlie g-ang-lia, tlieir investing" membranes, and the nerves, 
which issue from them, more particularly the semi-Uuiar g-anglia, cochac, and solar 
plexuses, of a scarlet and sometimes of a black colour. The psoas muscles, and 
the iliacus internus were black and easily torn. The pia mater, the brain were 
often, and the duodenum, except in two cases was always inflamed: The liver was 
generally more or less diseased: the stomach was also mostly inflamed: the coats 
of this organ, where no inflammation was found, were tender and easily torn.* 

Inflammation of the stomach or duodenum is not the occasional, but the most 
general symptom of the disease. The red eye; the inflamed stomach; the black 
vomit resembling coflTee grounds, and sometimes the orange-coloured skin, are 
the symptoms most commonly seen in this form of fever, and which almost inva- 
riably attend it. 

Such are the most usual symptoms of the 3'ellow fever. They 
will be seen to bear some resemblance to those of the plague, and 
the analogy between these diseases has been urged with much force 
by Sir J. M'Grigor. A more important analogy may be traced 
between the epidemic yellow fever and the genuine typhus fever 
of this country; and there can be no doubt, that the former bears 
the same relation to the endemic fever of the West Indies, that 
typhus does to the common synochus of Europe. It is properly- 
called therefore the typhus icterodes. It is the malignant fever 
of tropical climates, characterized, like the malignant fevers of tem- 
perate climates, by deep-seated affection of the brain, and extreme 
irritability of the stomach, but in a higher degree oi intensity. 

The cause of tlie yellow colour of the skin in this fever has been 
made a subject of inquiry. By some this appearance has been 
attributed to disordered function of the liver; by others, to bile 
absorbed from the intestinal canal without hepatic derangement. 
Sir Gilbert Blane has thrown out the idea, that it may be owing 
rather to a depraved state of the red globules of the blood. In 
whatever way this question may be decided, it is perfectly clear 
that the state of the biliary organs has very little to do with giving 

^. * Med. Recorder, for 1825, 6. 

21 



162 01' THE YELLOW FEVER. 

a character to this formidable disease, which is to be viewed as one 
of the most aggravated forms of typhoid fever. In respect of mor- 
tality, the yellow fever may even take precedence of the plague. 
At Gibraltar, in 1804, the disease raged among the inhabitants, 
uninfluenced by any distinction of age, sex, or condition.^ The 
deaths amounted to, somewhat more than one in three; a propor- 
tion, according to Sir Gilbert Blane, considerably above the devas- 
tation of the pestilence of the Levant. 

The treatment of the epidemic yellow fever is a point which has 
attracted great attention from all classes of inquirers; but their 
observations tend only to show that it is a disease of so singularly 
malignant a nature, as in a large proportion of cases, to bid defiance 
to all the efforts of art. This is particularly exemplified when the 
disease first makes its appearance in any town or district. The 
peculiar combination of circumstances, whether in respect of local 
situation, or of the state of the atmosphere, or of the constitution of 
the inhabitants, which gives the peculiar feature of malignity to the 
symptoms of the disease, operates also against the practitioner, and 
deprives him of all his most powerful means of combatting fever. 

To remove the sickness which- g-enerally appears early in tins disease, copious 
draug-hts of warm water, chamomile or eupatorium tea may be taken till full 
vomiting- is produced; and if the system is o]:)pre5sed, that is, if the skin be cold, 
the pulse feeble, fluttering, and no re-action likely to take place, then the practice 
of Cartwrig-ht mentioned below is advisable: r,hould, however, the irritability of 
the stomach continue throughout the disease, it becomes necessary to arrest it: 
for this pvn-pose lime-water and milk, given in equal parts, in the quantity of a 
wine glass full every two hours; spirit of turpentine twenty drops at the same 
interval; the carbonate of potash, ten grains, with a tea spoonful of lemon juice, 
or a table spoonful of vinegar; small doses of laudanum, eight or ten drops, with 
the same quantity of essence of peppermint; a blister to the stomach; sina- 
pisms to the same part; the same applications to the feet have also been useful: 
charcoalf in the dose of a tea spoonful every hour given in a little syrup, is said 
by Dr. Archer to relieve the vomiting even in desperate cases, with the greatest 
success; it keeps the bowels also in a laxative state. Soda water, iced lemonade 
were also valuable assistants. In some cases, a solution of the acetate of lead, as 
recommended by 13r. Irvine, of Charleston, (S. C.) succeeded with Ur. Archer: 
in others, the nitrate of silver, where the charcoal failed. The cb.arcoal has 
succeeded with Dr. Hill, of Wilmington, (N. C.) He gave it in lime water. C. 

The severe head-ache which characterises the early stages of the 
disease, naturally suggested blood-letting as a probable means of 
relief; but experience has proved that, though occasionally, it is 
not generally beneficial. The blood, when drawn, separates very 
imperfectly; upon exposure to tlie air, it docs not acquire its usual 
florid colour, and scarcely ever exhibits a huffy appearance. 

From the description given by Fowle, it appears that the disease is frequently, 
when very violent, a variety of piu'cnitis. The remedies advised under the iiead of 
phrenitis and hydrocephalus, of depleting the system by cold water, kc. jiourcd on 
the head, suggest themselves as the most appropriate; they should be continued 
as long as there is any stupor or redness of tlie eye, the patient being placed in a 

* Of a ])opulation of nine thousand, only twenty-eight persons escaped an attack 
of the disease. 

t Med. Record, v. p. 71. 



OF THE YELLOW FEVEU. 163 

semi-erect posture. From the dissections of Fowle, who saw the disease in its 
most acute form, in alow latitude, there was but little disease of the stomach; the 
morbid appearances were found after death to exist in the turgidity of the vessels 
of the brain: In phrenitis, Abercrombie states, that by pouring cold water on the 
crown of the head from a pitcher, holding a basin below the chin, he has seen a 
man reduced to syncope, from the most violent and raging- fury. Blood letting- 
is the next most advisable remedy; which, thougli t]\e author thinks is not gene- 
rally beneficial, must be considered as our main stay in this disease. 

On this subject, however, there is a conti-ariety of experience: Drs. Rush, 
McClean, Dickson, Bancroft, have succeeded with venesection, performed on the 
first or second day of the disease; Dr. Jackson advises it to be taken in large 
quantities, even to tliirty ounces; it prepares for tlie cold affusion, which it also 
renders more efficacious: he prefers one large bleeding to repeated small ones, as 
the best means of arresting it. Natives of a northern latitude when attacked in a 
southern one, require copious and early venesection, particularly the robust, the 
young and plethoric; the acclimated do not bear venesection well, nor do the 
natives of hot chmates: In the L'nited States, therefore, much will depend upon the 
previous winter; if cold and bracing, and if tlie situation be generally healthy, the 
persons attacked in the summer are more likely to require bleeding than other- 
vise: but this is a matter of experience; in all wide spreading maladies as their 
character varies with the season, actual trial is the only certain test of the efficacy 
of any plan: "When venesection is proper, it allays the fever, arrests tlie disposi- 
tion to local inflammations, favours the operation of other medicines, — the bath or 
purgatives, an-ests the progress of the disease and hastens recovery: It also pre- 
vents the supravention of dropsy and other disorders of debility. The blood 
exhibits every variety of appearance in this malady, and varies from the dissolved 
up to the buffy state. In employing it, however, it is necessary to guard against 
its excess, as it hastens the third or typhous stage. The practice of Dr. Cart- 
wright of Natchez is peculiar in this disease: Instead of bleeding immediately, he 
thinks that in the first stage or that in which the heat was unequally dililised, 
sensation impaired, and secretion suspended, or, in other words, wJiile tlie reac- 
tion was cri])pled and weak, emetics he found to h.ave an excellent efiect in pre- 
paring for venesection: an hour would elapse before the system appeared to feel 
the impression after taking the emetic; the iiTegular feelings of heat and cold and 
prostration throughout the system, gradually yielded to one of heat only; the 2ieat 
of the skin became uniform; great "distress would ensue; then nausea, retching, 
and at length, full vomiting; first of phlegm, then of bile." The system then 
seemed to succumb under the violent struggle; and after the vomiting the patient 
became easy; a short sleep followed; re-action and general fever tlien took place, 
which was accompanied with a hot skin, violent pain, a full, tense, and sti'ong 
pulse, with excessive miseiy. Tartar emetic given in the dose of from three to 
ten grains every one, two, or three hours dissolved in a small quantity of water, 
operated as a most powerful stimulus, rousing the organs from a state of palsy, 
with a slightly imtable stomach in the first stage, to a stage of open fever, with 
hot skin ajid hard pulse; thcH bleeding and purgatives were found useful in allay- 
ing the excitement which the tartar emetic administered in that manner had 
brought out; and mercury pushed to salivation afterwards, when the disease had 
been subdued, succeeded in eradicating- it. By g'iving tartar emetic on this plan, 
the first stage, or that of oppression was shortened, tne hot stage was developer/, 
a malignant disease was converted into a mild one, and often cured. The putipnt, 
after taking it, bore bleeding better, and also purging: It was, however, only 
suited to the first or oppressed stage of the disease; for when given whejc the 
fever was established it had a bad effect: Dr. Cartwright's experience wa? taken 
from the excessively hot climate of Natchez: farther to the north, where the cold 
or oppressed stage is not so aggravated, this practice has not been found ^o answer; 
Dr. Archer,* and most of the physicians of Philadelphia, have found ti'iat emetics 
establish and keep up the irritability of the stomach, and hasten the formatioi>'of 
the inflammatory state of that organ. Dr. Cartwright also found that if blood- 
letting were used during the oppressed state, before the hot fit commenced, that 



* Med. Uecorder, vol. v. p. 70. 



164 OF THE YELLOW FEVER. 

it quelled the efforts of the system to establish a general reaction, and rendered 
death certain, by debilitating- the patient, and preventing- the hot fit; but if he 
waited till the stage of heat was completely established, then bleeding- was very 
useful: of this the continual request of the patient for cold air, cold drink, a tense, 
full, and hard pulse was a sufficient indication. Blood could then be taken away 
by quarts; it reduced the heat, alleviated pain; and produced a soft state of the 
skin and pulse, and increased the susce]:)tibility to medicines; the secretions also 
became natural. Any direction of this kind will be found to apply only to parti- 
cular seasons: Like all other epidemics, the yellow fever requires different modes 
of treatment; and of this the experience of Dr. Rush afforded sufficient proofs: 
the active treatment of 1793 did not apply subsequently. Accordingly, if from 
the trial of the remedies, the disease be of a typhoid character, purgatives of 
calomel and jalap will be the most proper plan of treating it; entirely omitting 
bleeding, or practising it in small quantities. This plan will particularly apply to 
the acclimated; it relieves the head-ache, the irritability of the stomach, and has 
all the happy effects of more active depletion without its debilitating effects. C. 

The great object which it is found necessary to keep in view 
in the treatment of the disease, is the allaying that excessive 
irritability of the stomach, which leads to the black vomit. 
Calomel, given at first in a smart dose, so as to operate freely 
as a purgative, and repeated in smaller doses at intervals of 
three or four hours, so as to keep up this effect, was the most 
approved practice among the English practitioners at Gibraltar 
in 1813. To the calomel wxre occasionally united aloes and 
gamboge. In the exhibition of these medicines no time was 
to be lost; for it was only by their speedy and full effect, that 
the prevention or relief of the vomiting could be ensured.* Pedi- 



* After a full bleeding practised early the bowels should always be freely opened; 
and for this purpose calomel and jalap have been proposed by Rush; Dr. Cook 
recommends the ordinary purgative medicines as valuable in the following order; 
— calomel, aloes, rhubarb, jalap, scammony, colocynth, senna, and calcined mag- 
nesia: They produce coloured and consistent discharges, and relieve greatly: salts, 
castor oil and gamboge only produce serous evacuations :-[■ Calomel is advised in 
various doses: Some prefer small and frequently repeated portions; others large: 
The Trench practitioners in Philadelphia, the judicious Dr. Monges and others, 
relied dmost exclusively on the use of the gently purgative plan; they thought it 
had a good effect: a salivation, there can be no doubt, often suspends the disease 
and produces a rapid cure: this, however, is not always the case, as patients have 
taken this fever with a salivation upon them; and sometimes it has run its course 
in spite of the effect of mercury upon the mouth. Generally however, it an-ests 
it: the great objection is its power of operation. The patient dies before the 
mouth is afiectcd: Dr. Carlwright states that purgatives given in the first stage, or 
'^hat in which tlie system was oppressed, sometimes produces secretions from the 
bowels, which were followed by a reaction; or a general febrile and heated state 
of Mie system: AVhenever they produced copious, bloody, watery discharges or 
any highly irritative secretion, they were hurtful; If they were followed by a dis- 
charge of bile, they were salutary: Highly drastic purgatives, he thought very 
improper; because they debilitated excessively; and if the stools were serous, the 
patient became exhausted: When bilious they did good: the milder purgatives 
answered \\\c purpose better than any other, particularly the castor oil: It is taken 
easily, and lies well upon the stomach. t 

The use ot calomel, in the first stage of the disease, in the opinion of Dr. Cart- 
wright ])roduced generally no effect; and when it did, the ptyahsm did not subdue 
or arrest the complaint: It was only after the system had been depleted by the 
lancet or by other means, tliat the saUvation was salutary: It then produced a soft 

t Med. Record, vol. viii. Essays on Fever, liy Cook. | Ibid. vol. ix. p. 30-1. 



OF THE YELLOW FEVER. 165 

luvia, and tepid sponging were found beneficial. Under certain 
circumstances, the warm bath was administered with good effect.* 



skin and pulse, with a free secretion of bile and urine, and a return of feeling to 
the system: When the disease was permitted to run its course without depletion 
by the lancet, calomel, particularly when combined with opium, produced black- 
ness, sloughing-, and oozing of blood from the gums; or a temporary salivation, 
followed by hemorrhages; both of which subside; heat, dryness of the fauces, an 
alkaline breath follow, with a dry skin and tense pulse, red scanty urine and cos- 
tiveness; The mercury then excites an artificial fever which prolongs but does not 
cure the original one: His patients in this state generally died about the twentieth 
day; he however, gave to two an emetic, and they recovered: In giving mercury, 
he prefers small doses, so as to produce an effect sooner: It may also be excited by 
rubbing in the mercurial ointment in the quantity of ^i every three hours till it 
disappears on the surface of the skin: Sometimes enormous quantities are rubbed 
in before it produces its effect: In some systems mercury may be given for months 
without producing any change on the system: Calomel has been taken to the 
extent of nearly three hundred grains, and at the same time twenty drams of oint- 
ment rubbed into the surface before any effect resulted. 

A mode of exciting salivation in a rapid manner, by applying the fumes of 
mercury to tlie surface of the body and lungs, has long since been known in 
India, and deserves attention: Dr. Jackson, of Northumberland in this state, has 
succeeded with it in a short time; Pearson and Abernethy have also recommended 
it. The Hindoo plan is as follows, as stated in a letter from captain Sykes:f 

*' Our medical men produce salivation in twenty-four hours, and I have heard 
of a recent instance of its being produced in seven hours, by fumigation. My 
shastree, a learned Brahmin, asserts, that the practice of exciting salivation, by 
means of inhaling mercurial vapour, has been used by the Hindoos from time 
immemorial. Bees-wax is melted, and spread over strips of thin cotton cloth; an 
equal quantity of cinnabar in powder is spread over the waxed strips, which are 
then rolled up in the shape of candles. The person to be salivated is seated on 
the ground and a blanket is thrown over him; the lighted cinnabar candle is placed 
under the blanket, so that he inhales the vapour." 

The mode, used by Dr. Jackson of Northumberland, consisted in subliming a 
mercurial preparation given below, and receiving it into the lungs and on the 
external surface: It is made as follows: "Two drachms of aq. amm. are added to 
six ounces of distilled water, and four ounces of calomel are thrown into this 
liquor, and shaken with it; the powder is then separated by the filter and dried. 

" This is the preparation wliich was used by Pearson and Abernethy, for the 
peculiar fumigations recommended by Lalonette; but to tliis we shall add for the 
convenience of those who may not have the aq. amm. at hand, that the sp. amm. 
either simple or aromatic, is equally suitable. Rain or river water may be used 
when the distilled is not to be procured, and the medicine can be prepared in a 
single hour." 

The instrument, used for this purpose, consisted of a common tin funnel; below 
which, was sublimed the powder, thrown in the quantity often grains on a red hot 
iron and inspired into the lungs; the powder is renewed, as it subhmes, repeating 
it from two to six times, at the interval of two, four, or six hours; it often salivates 
the attendants, if they are not careful: He has salivated a patient in twelve hours: 
applied to the skin, in the Indian mode, it must succeed earlier. C. 

* In yellow fever, when the secretion of the kidneys had been suspended, Mr. 
Cartwright found that the administration of diuretics formed a valuable assistant in 
depletion; and equally so, as purgatives which in many cases only produce a serous 
debilitating and ineffectual evacuation: as soon as the diuretics began to operate, 
the liver and skin soon took on their appropriate secretions, and the disease 
yielded. t 

Diaphoretic remedies are generally too feeble to operate in this disease: Its 
march is too rapid: Sometimes in the experience of Cartwright, however, they 
tended to re-establish the secretions of the liver and skin, when other medicines 

t Am. Med. Journal, vol. 1. p. 52i-d. J Med. Hecord. vol. ix. p. 34. 



166 OF THE YELLOW FEVER. 

Cold applications to the forehead and hands occasionally served to 
relieve the urgent headach. 

AVith reg-ard to the cold aifusion, it must be used according" to the rules formerly 
laid down under the head of continued fever; i. e.when the pvdse and temperature 
are steadily above the natural standard: If used when the skin is cold, pulse low, 
feeble, and fluttering; great shivering and coldness are the result, without fever; 
the disease passing at once into the last stage, in which all the symptoms are of a 
typhous character:* 

The efiicacy of this remedy is confirmed by many authorities; by Dr. Miller, of 
New York, O'Leary and McClean: In 1793 in Philadelphia, it did not succeed: 
Like all other remedies, it fails in many cases, though its general usefulness is 
unquestionable. In the cases in which it was tried in New York, it succeeded in 
all in which it was used, in the first days of the disease: afterwards it hastened the 
fatal catastrophe.-}- Calomel was given at the same time, though no salivation was 
produced. The temperature may be reduced in hot climates by putting salt in 
the water before the affusion, if it cannot be got from springs of a temperature 
sufficiently low 4 The other means formerly mentioned of sponging the body 
with vinegar and water, spirits and water, xther and water, to cool the surface, 
care being taken to place the patient in a current of air, so that he may not be 
stimulated by the inhalation of the aether, will be found useful. C. 

When the powers of life appeared to fail, it is unnecessary to 
say that stimulants and cordials were had recourse to. § Subacid 



were of no avail. The well timed use of more active remedies and plans generally, 
however, preclude their use.il Dr- Archer of Norfolk in the year 1822 found, that 
after bleeding in the first thirty-six hours of the disease and free purging with 
calomel and jalap, a complete diaphoresis succeeded: For this purpose the cold 
affusion, and if that failed, sponging the skin with hot vinegar and water, at the 
same time giving the patient copious draughts of hot lemonade, balm or sage tea, 
and covering the patient up in the bed, frequently cut short the fever, and cured 
it completely: The diaplioresis allayed the vomiting: and in the last stage, the 
infusion of serpentariu greatly assisted in this object: Frequently, the use of the 
James powder with small doses of calomel, was useful: its efiect, however, in 
increasing the irritability of the stomach too often contra-indicated its tendency 
towards the skin. 

Epispastics*when thought necessary should be of the most active kind: They 
are useful in the stage of prostration before the hot fit begins; or in that of debihly 
after it is past: The most active should be used: sinapisms will generally be found 
to answer better than blisters:^ and to prevent the formation of the diseased action 
of the stomach, equal parts of the nitric acid and water, as practised in the eastern 
cholera, applied over the epigastrium, is valuable: The volatile spirits of ammonia, 
applied by dipping a piece of muslin in it, will also be found to be useful: Sina- 
pisms may be applied to the ankles, wrists, and to the spine, to excite the system, 
either in the cold or debilitated stages of this complaint. The spirits of turpen- 
tine, alone or boiled over cantharides, is useful from its speedy action and exces- 
sive irritation. The tincture of capsicum, with violent frictions of the surface, are 
found to be valuable; in fact, in the last or typhous stage, even these arc often 
useless. C. 

* Cartwright's Essay in Med. Record, vol, ix. p. 35. 

f Tiiomas' Practice, p. 91. ^ Ibid. 

§ 'l"hc articles formerly mentioned under the liead of typhus fever, will in this 
stage be proper — sinapisms, blisters, poultices of horseradish, to the wrists and 
ankles: Carbonate of ammonia, musk, opium, castor, wine, l)raiuly, with nourish- 
ing soups, and the farinacca: The sul])h:ite of quinine, the bark, in powder or 
decoction, witli the mineral acids, and if the bark be not retained, it may l>e givLii 
in injection.** The room siiould be perfectly ventilated; and the most perfect 
* cleanliness observed about tlie person. C. 

U Med. Recorder, vol. i.\. p. 31. IT Ibid. p. 00. •• Tliomus' rractice, p. '.•2. 



OF THE YELLOW FEVER. 1G7 

drinks were given, and a strict antiphlogistic regimen pursued 
through the whole disease. The same rigid attention to diet and 
regimen were required during the period of convalescence. * 

In g-enera], this disease is of an inflammatory character, the use of stimulants, 
therefore will be improper; opium has always been pernicious except in the last 
or typhus stag"e: Dr. M*Lean states that it was useful when convulsions took 
place, and when there was delirium, towards the decline of the disease, it pro- 
duced sleep; as soon as the remission is fully established, the sulphate of quinine, 
or any mild bitters, the quassia, columbo, and ang-ustura, will be then found to be 
valuable. The j^enuine ani^ustura, is thin, smooth, of a yellowish coloured frac- 
ture, and of a bitter aromatic taste: The poisonous kind is less thick, white or 
yellowish white, gray in its fracture, on the inner edg-e yellowish, approaching to 
brown, of an unpleasant bitter taste, and with a little aroma.j The latter is 
equally noxious with nux vomica in its effects. C. 

I have stated, that among the points in dispute regarding the 
yellow fever, is the question of the identity of the epidemic yellow, 
or Bulam fever, with the endemic fevers of the West Indies. 
Upon this question an opinion has already been given. 

The three signs ordinarily believed to identify the yellow fever; the red eye, 
black vomit, and inflammation of the stomach, appear in the fevers of summer in 
the east and west: The yellow fever assumes all the types from the intermittent 
to the continued; the black vomit, thought to be so peculiar to it, occurs in the 
agues of Minorca, and the red eye also is found in the bilious fevers of this country: 
Fevers of all kinds, particularly those of any particular season, vanish into each 
other by such insensible gradations, that it is impossible to draw an exact line of 
separation between them, except as to intensity; which is best measured by the 
rapidity with which they produce death, or derange the important functions of 
the system: Thus, the intermittent, the remittent, and continued, and typhus 
fevers of summer and autumn, the cholera and dysentery of the same seasons, 
change into each other, are owing generally to the same causes, and are cured by 
the same treatment, and differ principally in the intensity with which they attack 
different organs, particularly those more immediately necessary to life. C. 

The other topics of controversy are, first, whether the disease 
be always imported, or whether it can ever be generated by a 
combination of common or endemic causes; — secondly, whether, 
being once received into a town, it propagates itself by contagion; 
and thirdly, whether those who have passed through the disease 
are susceptible of it a second time. These are all important ques- 
tions, the replies to which are not so obvious as to that of its 
pathological affinity, which has already been under discussion; and 
they involve the most difficult parts of the controversy. 

The first question is undoubtedly one which should be answered 
with some caution. Many circumstances connected with the early 
appearance of the epidemic yellow fever at Philadelphia in 1793, 
and in Gibraltar in 1804, strongly favour the idea of its having 



* For many of the remarks contained in this chapter, I beg to express my 
obligations to Dr. Fraser, Deputy Inspector of Hospitals at Gibraltar, who has 
obligingly given me access to his voluminous and valuable documents on the 
yellow fever. 

t Thomas' Practice, p. 93. 



168 OF THE YELLOW FEVER. 

been in those situations an imported disease. Several other facts 
however mi^ht be adduced, which militate against the universality 
of this doctrine; and there is nothing inconsistent in allowing that, 
though it is sometimes imported, the genuine malignant yellow 
fever may? under circumstances favourable to its developement, be 
generated in any warm climate by a combination of endemic causes. 
With regard to the second question, no reasonable doubt can surely 
be entertained b}^ any candid, intelligent, unbiassed man, that this 
disease, being once received into a town, is contagious. The evi- 
dence in favour of this opinion is certainly as strong as for that of 
the contagion of typhus, or of plague. Whether the yellow fever 
bears the greater analogy to the former or latter of these diseases, 
may indeed be disputed. We may deny that there is any thing 
specific in the contagion of yellow fever; but that the disease is 
propagated by contagion of some kind, cannot be questioned, after 
the ample experience w^hich has been had, both in America and 
Europe. If any doubts could have been entertained while the 
disease occurred only in the West Indies, in consequence of the 
resemblance of the epidemic to the endemic fevers of those islands, 
they must have yielded to the obvious arguments suggested by its 
appearance in Cadiz, Gibraltar, and still more lately at the Island 
of Ascension.* The contagious nature of the disease, it may be 
remarked, is a question w^hich is perfectly distinct from that of its 
foreign or endemic origin. 

Some of the laws of the contagion of yellow fever appear to be 
ascertained with tolerable accuracy. Its latent period varies from 
two to eight days. Ten days is, I believe, the longest period 
recorded of yellow fever appearing, after exposure to the contagion, 
and removal to a freely ventilated atmosphere. The contagion of 
yellow fever has a peculiar range of atmosplicric temperature, but 
on a higher scale than that of the plague. It has never been known, 
but in those countries and at those seasons when tropical heats, 
that is, of eighty degrees Fahrenheit's, or upwards, prevail. It 
never fails to disappear as the winter approaches. It is certainly a 
singular circumstance in the history of the yellow fever, that it has 
never prevailed to any extent at a distance from the sea, nor, except 
in a few instances, but on the shores of the Atlantic Ocean. 

It has been observed by Dr. Carlwrig-ht, to occur in a small town at a distance 
from any g'rcat water near Natchez, and to be produced in that situation, by the 
putrefaction of animal substances. Tlie repeated facts from the interior of our 
country, on the lakes, Sec. leave no doubt upon the mind, that nothinj*- but suffi- 
cient putrefaction is required to produce this disease, independently of the 
Atlantic or any other ocean: Tiie author surely should recollect, that at IJatavia 
it is the yellow fever, which destroys so many Europeans every year; It occurs 
also in other parts of the East Indies: It is by no means unfrequcnt in ]?engal;f 
Cleghorn speaks of the black vomit in the agues of Minorca: What particular 

* Consult Dr. Burnett's «' Official Report of the Fever which appeared in his 
"Majesty's Ship Uann, and the Island of Ascension, in 1823." London, 1824. 
t Wade on the Treatment of Fever in Bengal, p. 75. 1793. Lond. 



OF THE YELLOW FEVER. 1G9 

quality can be connected with tlic Atlantic ocean, it is difficult to conceive: Tlie 
supposed distinctive qualities of the )'ello\v tl^ver, the black vomit and red c3e, 
occur in the fevers of the interior of this country: They even show the malignity 
of the plag-ue in some instances.* 

The last circumstance which it is of importance to notice in tlie 
history of the yellow fever and the laws of its contagion, is the 
question whether it can be taken a second time. The answer is a 
very short one. Although a few well attested instances to the 
contrary have been recorded, still a most extensive experience has 
satisfactorily proved, that the immunity from second attacks is 
nearly complete, and that it forms one of the most striking charac- 
teristics of this remarkable disease. 

This by no means accords with our experience in this country. The yellow, 
like all other fevers, of course, leaves the person less susceptible: the debihty 
produced by it alone will be sufficient to account for this fact: Dr. Rush, relates 
many instances where it was taken a second time, and some of which were in the 
same season. At New Orleans the same fact has been amply confirmed. Dr. 
Potter in the following- note expresses his opinion, on this interesting question: C. 

The annals of our country put this at rest. It is true, that in countries uniformly 
hot, the disease is seldom observed to occur more than once in the same subject, 
but in all countries where the winters are cold, we find very little difference in 
the susceptibility to the cause. The emigrants from St. Domingo, were exempt 
from the yellow fever of 1797 and 1810, in this city, (Baltimore,) but in 1819, 
1821, they suffered as much, c?eteris paribus, as any other variety of the human 
species. 1 have remarked in my notes of 1821, that since 1793, I have attended 
more than a hundred persons in a second attack — Tweniy-one in a third — Stvcn in 
a fourth — Three in a fifth, and one in the eighth attack of yellow fever. P 

The diseases of plague, intermittent, and i-emittent fevers, and yellow fever, 
appear in the hot season, they are therefore principally to be dreaded by strangers 
going to hot countries: They attack the young and plethoric, and those coming 
from the north: Depletion of all kinds has been found useful to prevent these 
diseases: At Batavia, a gentle purge of sulphur given daily, prevented the disease 
in a whole ship's crew:f a continued perspiration has been said to answer the 
same end. Exercise in the open air before the heat of the day, is particularly 
valuable; and if obliged to do any duty, or labour in the sun towards noon, it 
should be as short as possible: All the plans of prevention should be carried so 
far only as is consistent with the strength: fatigue and debility should be avoided: 
all excesses are therefore improper: The diet should be plain, simple, moderate, 
digestible, and nourishing. 

Fork is considered, in hot climates particularly, an im.proper food, as it frequently 
predisposes to diseases of the skin: mutton, beef, and fowls, boiled will be most 
proper, avoiding all spirituous liquors, particularly punch; porter, lemonade, beer, 
or wine, may be taken: 

Habit, of course, renders proper indifferent individuals various kinds of diet; 
that which is most eaten in their youth, is generally digested with the least ex- 
penditure of strength: To Europeans and Americans, it will be found, that the 
above articles are most nourishing, and keep the system in a healthful and easy 
state; butter and fruit, should be taken sparingly; turtle and sea-fish are healthful: 
Dr. Rush advises a proper mixture of vegetaloles, and that no sudden transitions 
from an animal to a lov.^ diet, should be made, as it would have the effect of bring- 
ing on the disease; suppers are hurtful: the liighest degree of strength consistent 
with health should be promoted, and this is best done by a diet of animal food, 
with a small admixture of vegetables. 

Cold bathing is very common in hot countries; to the intemperate, it is danger- 

* Hildreth's paper. Philadelphia Journal for Nov. 1824. 

f Rush, vol. iv. p. 193. 

22 



170 OF THE YELLOW FEVER. 

ous; Dr. Clarke g-oes so far, as to consider it as mortal: It is not advisable, where 
there are obstructions of the liver and spleen: of all people, water drinkers are 
always safest in warm climates: the only objection to abstinence from ardent 
liquors is, that the appetite becomes too good; the effect of this, however, will be 
obviated by taking- an aloetic pill occasionally, or some gentle cathartic medicine. 

If the country, which a stranger visits is very unhealthy, besides depletion by 
one or two bleedings, and purges, a gentle effect of mercury on the mouth will 
be advisable, and a very temperate life; a salivation, however, does not always 
succeed. Clarke recommends, that in Dominica, oflicers and men returning from 
fatiguing duty, should be purged freely to prevent the fever: AVade says, that in 
India, they should be taken before the nevv^and full moon; it has been conjectured 
from the recession of the tides at these periods, that the exhalations are greater; 
of com'se the causes of disease are more active.* The French from their more 
temperate habits in the West Indies suffer less than any other people. 

The necessity of the reduction of strength before removing to a warm climate 
is shown, by the effect of the climate on those, who have resided long in it. They 
become debilitated, from tlie relaxing effect of the heat, and the perspiration; 
the consequence is tliat they are not subject to these violent diseases, and when 
they are attacked they recover more rapidly. It is also shown by the circum- 
stance that direct depletion prevents it. The loss of blood saved a whole 
regiment in the West Indies lately arrived from France: in 1741, it prevented the 
yellow fever, in many persons in Virginia.t Foreigners shoidd avoid the wet and 
rainy seasons of all tropical countries — from March to December. Confinement in 
the middle of the day; avoiding the morning and evening air, and sleeping in the 
open air in the night; the use of umbrellas, or other protection, when in the sun; 
flannel worn next the skin; good shoes to keep the feet dry; cloaks to prevent the 
effect of the chilly, morning and evening air, will be found to be useful: 

The black hat often produces apoplex}' from the excessive heat of the sun in 
tropical countries: the change at sunset, when the dew falls suddenly and heavily, 
cannot be easily appreciated by a native of a northern climate, till he has witnessed 
it: these remarks apply to the valley of the Mississippi; the same di'ess, and mode 
of life is proper there as in India, wliich is that just specified. 

The residence should be on a higli, airy, and dry situation; and if this is imprac- 
ticable, the highest ajiartmcnt of the house should be chosen to sleep in; it should 
be furnished with a small stove and a fire to ventilate the room; in all cases, 
particularly in cold climates, the use of fuel should be free, if the room be damp 
and chill: Many diseases of tlie army arise from moisture and cold: The windows 
fronting marshes should be shut: Smoking and drinking to excess should be 
avoided: The rule of Cclsus, "Si qua intemperantia subest, tutior est in ])otionc 
quam in esca," applies l^etter to temperate than to warm climates; Intemperance 
in drinking is particvdarly dangerous in hot countries: Early rising, and retiring 
early, and bathing in cold water, will be salutary: "NA'et clotiies should be changed 
as soon as ])ossible, and all debihtating" circumstances avoitlcd. 

With regard to the liealth of soldiers, Pringle recommends that trenches should 
be made round tents to lessen the moisture of the ground, and drain oil' the water, 
without wetting the straw, and other materials liable to be injured; the frequent 
renewal of straw, airing tiie tents by frequently opening them, to make everything 
about them dry, sliould be carefully attended to: the mattrasses of the officers 
should be raised from tiie ground, wiiich should be covered with an oil cloth, to 
intercept the vapour, keejjing- the tents airy in all seasons; tiie banks of large 
rivers, jjrovided they are dry, sandy, and higli, arc most fiwounihle situations for 
an encampment; airy villages, not too much secluded by trees, which arc removed 
from water, are most healthy for the same purpose. 1 l'rcc[ucnt removal of a camp, 
to choose a new and clean situation; the estul)lishmcnt of deep privies, throwing a 
thick layer of earth into them daily, till the pits are full, and then digging others; 
always in situations to prevent the reigning wind of the season from [flowing over 
the camp, deserve attention. The hospitals should be small, well aired, and venll- 



liush, vol. iv. p. l'J5. 18{Ji). 
Irish's Fringle, p. o7. 1810. 



OF THE YELLOW EEVEU. 171 

lated; open airy barns and churches are to be preferred to close houses, as hospi- 
tals, in summer; those who liave inflammatory diseases v,'i\\ not bear to be removed 
\vith the army; the typhus patients are l)enefittcd by it; this however apphes. Dr. 
liusii states, to removals in summer; in winter it does injury: The patients in each 
hospital should be few; in winter hospitals, chimneys should be used; stoves never; 
a cabin, with a lire in the centre, and a hole in the roof to let the smoke pass, the 
beds being arranged round the fire, formed, during the Avar of 1776, good hospi- 
tals; the smoke was only disagreeable during tlic time of kindling the lire: Plenty 
of good food and drink, of fuel, with comfortable clothing, regular exercise, at 
proper times, are also to be attended to.* 

In hot countries, the expeditions undertaken by soldiers should be short and 
rapid: six weeks' exposure has reduced an army so rapidly as to threaten its 
existence. The buccaneers in South America always retained their health, 
because they did not stay long in one place. Soldiers should in all tropical 
climates be regarded as children, who must be taken care of by the vigilance of 
their officers; natives should be employed in hot climates to do any duty at night 
along shore, as, to northern men, it is invariably fatal; The occupations alluded to 
are, burying the dead, cutting wood, &c.; and if the men get sick, the best place 
for them, both to prevent further sickness, and to recover from it, is in a clean 
well ventilated vessel in the middle of a river: the well should take the bark twice 
a day, and purges twice a week.f C. 

* Rush's Pringle, p. 99. 1810. 
f Clark on Long Voyages. 



( 172 ) 



CHAPTER IX. 



MILIARY FEVER. 



Synipto)ns — Causes — Type — Treatment. 

SYMPTOMS. 

The symptoms of the miliary eruption* deserve to be here noticed, as it is by 
some considered as a fever of a distinct species. Numerous small red pustules, 
preceded by aroug'hness produced by cold, appear upon the skin: Distinct, some- 
times in clusters, so prominent as to be easily felt but not seen, often of the colour 
of the skin, they produce in ten or twelve hours a whey coloured vesicle, which 
soon becomes white. When the state of the vesicle is a little more inflammatory, 
the pustules are red, and the fluid, in them, turns yellow: in two or three days 
they fall off in scales. The fluid is acrid and of a bad smell: on the neck and 
breast they are first seen; they appear and disappear repeatedly in the course of 
the disease: The degree of fulness, redness, and its steadiness after it comes to 
the surface, determine the character of the eruption, for it is favourable in pro- 
portion. 

The symptoms of fever often increase before the appearance of the eruption; 
pricking- and itching- in the skin and bowels, with numbness of the extremities, 
particularly of the fing-ers and toes; delirium, pain in the head, ring-ing- in the ears, 
pung-ent heat in the back, a sour rank profuse sweat, with a small pulse often 
precede the eruption: also epilepsy, inflammation of the eyes, with a watery state 
of them, and aphthae: these symptoms are reheved by the appearance of the 
sweat, which, if not checked, causes tlie continuance of the eruption for many- 
days. 

A moderate sweat, free breathing-, without much debility or depression are 
favourable symptoms, and the contrary. 

A watery discharg-e from the bowels, kidneys, or a salivation preceded by rest- 
lessness, sickness, anxiety aiid a sense of sinking-, attends even those cases which 
are without fever: the red variety is less frequently accompanied by fever than the 
white. 

Miliary fever may be considered as sometimes dang-erous, as the patient dies, if 
the perspiration is suppressed; this, however, often occurs from the excessive 
debility, produced by the copious discharge exhausting- the system. 

CAUSES. 

A damp atmosphere, excessive evacuations, particularly of blood, copious men- 
struation, fliior albus, a bad diet, a moist and marshy air, intemperance, excessive 
venery produce it. The old and the very young, and women, are more subject to 
it than men or the more robust: oflTending matters in the primx via: produce it; 

■ * — — — ■ — — — ■■ 

• We are indebted for the facts and descriptions of this essay to the work of 
Wilson Philip, vol. i. p. 29G. 



MILIARY FEVER. 1 73 

and it Is removed when they are discharg-ed. In spring' it is most common; in 
autumn next; summer next; and, lastly, in winter it is least frequcHt: changeable 
weather is most favourable to it. 

TYPE. 

The type of this fever generally inchnes to typhus, from the excessive discharge 
by the skin which accom])anies it: When it occurs in a typhus it is generally white, 
and when in synocha, it is red, owing to the increased impetus of the blood. 

TREATMENT. 

With regard to the treatment of miliary fever, it is to be managed in the same 
manner as other fevers, only so far as the eruption m.odifies it. The application of 
cold is reg-ulated on the same principles as stated above, when the disease is syno- 
cha; and when the temperature falls nearly to the natural standard in typlius cases, 
instead of cold applications, sulphuric acid and alum, and the bark will be found 
to be valuable.* If the stomach is oppressed, if there be headach, nausea, eruc- 
tations, griping, or swelling of the belly, an emetic becomes necessary, with 
diluents; avoiding at the same time excessive dilution, for fear of increasing- the 
sweat, and of course the debility. The connexion of the miliary eruption with a 
disordered state of the stomach must be kept in view. 

AVith regard to the retrocession of the eruption, as a cause of subsultus, delirium, 
&c. there can be no doubt but that it is owing entirely to the exhaustion produced 
by the perspiration; its regulation must therefore be managed with judg-ment; 
exposing the patient to cold air gradually, by first lightening the bed clothes, 
giving him cold drink, &c. 

If there be inflammation in the viscera, or if the fever be violent, particularly 
when it arises in inflammatory habits, accustomed to high Uving or the abuse of 
spirituous liquors, or from the suppression of the lochia, bleeding becomes neces- 
sary; When the sweat retrocedes and is attended with subsultus tendinum and 
other typhous symptoms, the use of cordial and stimulating medicines become 
proper; as, musk, ammonia, camphor, &c. as above recommended: the system 
must under all circumstances be supported, as debility is the principal feature of 
the disease to be guarded against. 

* Philip, vol. i. p. 30T» 



CLASS II. 

THE EXANTHEMATA, OR ERUPTIVE FEVERS, 



CHAPTER I. 

THE EXANTHEMATA IN GENERAL. 



Objects of Inquiry in this Chapter — Character of this Order of 
Diseases — Their Relation to Simple Fevers — Defined Charac- 
ter and Course of Exanthematous Fever — Defined Character 
of the Eruption — Their Occurrence but once 171 Life — Excep- 
tions to this Law, and attempts to explain them — Their 
Origin fi^om Specific Contagion — Relation of the Exanthe- 
mata to the other Morbid Poisons — Peculiarities of Specific 
Contagions — Communication by hioculation — Latent Pe- 
riods — Incompatibility ivith one another, and with other 
Diseases — Criticism on Dr. Willaii's Arrangement of the 
Exanthemata — Their Connexion with Diseases of the Mucous 
Membrane. 

OBJECTS OF INQUIRY IN THIS CHAPTER. 

The class of exanthemata, or eruptive fevers, is that to which 
our attention is next to he directed; and as the diseases which it 
comprises present many points of analogy, and several peculiarities 
which distinguish them from other complaints,* it may be advan- 

* Wc call small-pox, measles, and some other eruptive fevers, specific contag-'ions, 
because they are accompanied by a more uniform train of symptoms than other 
fevers, always communicating" their own similitude, except any deviation that may 
arise from a difference of constitution. They are diseases that can only be 
imparted once to the same body; but iherc is another difl'crcncc, if not a ])ecu- 
liarity, in the character of specific contag-ions. They require tlie aid of no excitint; 
or other cause to bring- them into existence, and devclopc all their phenomena. 
If the cause once lmpin,ge upon the nerves, notliing" can entirely avert its conse- 
quences. Sucli is not tlie effect of otlier ag-ents acting- as remote causes. Marsli 
miasmata, a low temperature, and many other causes that lay a ]>redisposition, 
may disable one or more functions of the body, and tlius predis|)ose them to 
disease i but the cll'cct of such agents may pass away, and never be followed by 



THE EXANTHEMATA IN GENERAL. I75 

tageous to offer some general remarks upon the class, previous to 
examining its component parts in detail. My object on this occa- 
sion will be to point out the pathological relations of the exanthe- 
mata, and to give a general idea of the objects of investigation in 
the five following chapters. With this view, I shall direct my 
attention to the relation which they bear to simple fevers, to one 
another, to other diseases arising from morbid poisons, and to 
cutaneous diseases. These objects of inquiry involve the considera- 
tion of some of the most important laws which regulate the plieno- 
mena of disease, but they can only be very briefly touched upon 
in this place. 

CHARACTER OP THIS ORDER OF DISEASES. 

Idiopathic fevers were formerly stated to be of three kinds, 
continued fevers, intermittents, and the exanthemata. The latter 
may be viewed as continued fevers, to which an eruption is super- 
added; and a great deal of what has been said regarding the general 
doctrine of simple fever, particularly all that part which relates to 
the prognosis and principles of treatment, will be found equally 
applicable to the case of fever complicated with eruption. The 
consideration of the exanthemata naturally follows that of fevers 
strictly so called; by such an arrangement we shall be able to 
exhibit, in a connected view, all the leading doctrines of febrile 
disease. 

The genuine exanthemata are small-pox, chicken-pox, cow-pox, 
measles, and scarlet fever. There are a few other diseases of lesser 
importance, which, as allied in some respects to these, may be 
arranged in this division of the w^ork, under the title of the minor 
exanthemata; but our attention in this chapter will be exclusively 
directed to the former. The following is the common character 
of the exanthemata. 1st. They are marked by the presence of 
fever, which runs a defined course. 2d. They are attended with 
an eruption, which like the accompanying fever, goes through a 
regular series of changes. 3d. They occur to every individual 
once, and only once, during life. 4th. They arise from specijic 
contagion. 

THEIR DEFINED CHARACTER. 

1st. The first peculiarity of the exanthemata is the defined 
character and steady course which the accompanying fever exhibits, 

the diseases that would result as consequences, if an additional cause were 
superadded. 

Tlie distinction between the exanthemata and other inflammatory fevers of the 
greatest importance in practice, seems to be the deceitful weakness of tlie pulse, 
which seems to be occasioned by the impression made by the poison upon the 
nervous system, impairing the contractile ]io\vers of the heart, while some of the 
viscera labour under great congestion, and some under inilammation. P. 



176 OF THE EXANTHEMATA IN GENERAL. 

under almost every variety of external circumstance and habit of 
body. Here we trace a very marked and obvious distinction 
between exanthematous and common continued fever. It is a 
feature however in the character of the exanthemata, which, though 
applicable as a general principle, requires to be received with some 
qualification. It is strikingly illustrated, indeed, by the phenomena 
of small-pox and measles, but it is less distinct in the scarlet fever; 
and in the cow-pox and chicken-pox, very little fever is discernible 
at any time. The character of the exanthematous fever, except 
in the case of one form of scarlatina, is inflammatory, and this it 
assumes in the young and the old, and in all varieties of climate, 
season, and situation. The regularity in the course of exanthema- 
tous fever is well shown in the three days of the eruptive fever of 
variola, and the eight days of its fever of maturation. These curious 
facts form a striking illustration of the doctrine of critical days in 
fever, and of that principle of periodic movement in the animal 
economy, regulating many phenomena both in a state of health and 
disease, to which we formerly referred. It is a singular circum- 
stance, that this corroboration of the doctrine of critical days should 
not have been known till above a thousand years after that principle 
in pathology had been inculcated. 

Upon the whole subject of the peculiar nature of the exanthemata, we differ 
considerably with the author, and these are our reasons. 

I. He slates, that these diseases are marked by a steady and defined course. We 
proceed, then, to examine them with reg-ard to all the modes of this attribute. 
AVith reg-ard to the duration of their fever, observation proves that they are equally 
as varied as the phleg-masiae, or any local inflammation with fever; as to small-pox, 
this is entirely true; its fever continues for one, two, or three da}'s, or sometimes 
it is without fever entirely; thus the varioloid, which is now acknowledg-ed to be 
the same disease as small-pox, (for by inoculating- with the matter of the varioloid 
the small-pox is produced,) often has no fever, or a fever from the shg-htcst dcg-ree 
up to that of the most malig-nant small-pox: the variolous fever also occurs without 
the eruption, as in the epidemic small-pox mentioned by Sydenham: 

With reg-ard to measles and scarlatina, the same is true; in the measles, the sore 
eyes and thi-oat, and eruption appear without fever at all; at other times, the fever is 
slight, continuing- from one day to eig-ht or foiu'teen,* before the eruption appears. 

Scarlatina also commences with a mild fever. IJuteman describes its simplest 
form as merely a rash, with almost no fever or illness, or with a moderate degree 
of itj-j- whilst its most violent form produces death sometimes on the thirds day: 
and, as Schultzius says, upon the first or second. § So much for the degree of 
fever; like the phlegmasia, ice. as we have stated, it occurs with the mildest affec- 
tion of the general system up to the most severe: a defined and steady degree of 
fever cannot then be considered at all as a distinguishing feature of the exanthe- 
mata. 

If we judge of this characteristic by the description given in the books of a 
particular form, it will be easy, by taking that as the standard, to find instances 
which will tally with it; thus', like intermittent fever to a person who has read 
Cullcn's description only, it will appear to consist of a series of changes, succeeding 
each other with the greatest regularity; but when we consult nature, this is not 
found to be the case; intermittents are found of every variety of degree; with chill, 
without it; with a fit, consisting wholly of chill, or wholly of fever; and of fever 



* Rush, vol. 2, 426. 1809. + Withering, 1779, p. 8. 

f Rateman, p. 69, 70. Phil. 1824. § Ibid. ]). 32. 



THE EXANTHEMATA IN GENERAL. 177 

with cliill and without sweat, of sweat alone, or running" through all the variety of 
permutation, of which these different phenomena are capable; as regards dura- 
tion, kind, and every other quality, also in addition exhibiting even the combina- 
tion of all other diseases, of some of the exanthemata, nay, of even the itch,* which 
is generally considered to be the product of an insect: It is difficidt to reason on a 
subject so as to produce conviction, where the dogmas of the schools and of books 
are taken as the criteria rather tlian those of nature; tiic creeds, the assumptions, 
and too often fictions of the science, as taught us in our early youth, recur to blind 
the eye to nature, and lead us astray from the open road to truth: they rise, Uke 
the ignis fatuus of the night, or the mirage of the desert, to delude and to decoy; 
addressing the ear alone, they place one sense in rebellion against all the others, 
and against the mind itself, and give it the rule of the whole reasoning powers; 
with such a pilot at the helm, the syren song of imaginary excellence occupies us, 
whilst the whole circle of disease, its endless variet}' of phenomena, its dangers 
and their remedies, should be the paramount, the engrossing subjects of thought. 

The author, then, is wrong-, when he draws a line of distinction between con- 
tinued and exanthematous fever, by saying that the latter is more regular; for in 
all its forms, it occurs in every variety of degree. This is true in fact of almost 
all diseases; thus, to a person acquainted only with books, pleurisy is one of the 
simplest and most regular forms of the phlegmasia, yet it occurs complicated with 
all varieties of fever, from the simplest intermittent to the highest state of inflamma- 
tory, or the lowest typhous fever: in its local symptoms, from a variety, in which 
there is no pain whatever, to the most acute and sensitive state of the local affec- 
tion; it is complicated with inflammation of the lungs, of the bowels, and even 
the muscles of the chest, which has, in some instances, run so high as to be 
attended with sphacelus, and sloughing of the side.f Appeals to nature only can 
decide this matter. 

With regard to the regularity of the course of small-pox given as a good illus- 
tration of the doctrine of critical days in fever, and of the disposition of the system 
to observe certain states and periods; this is sufiiciently disproved by what has 
been said above, that fever in the varioloid and small-pox occurs in every variety 
from its lowest and almost imperceptible degi'ee, up to one that continues for 
many days. The evil of this disposition to introduce mathematical precision in 
disease, however, is not confined to doctrine, it has a material influence upon 
practice; thus, with regard to vaccination, when perfect, it is said to require a regu- 
lar stated period of three days after the insertion of the matter before the pimple 
inflames; and the formation of the areola by the eiglith day; and then to secure 
the system from danger from small-pox; and this dogma has been taken as certain, 
and great feeling has been excited by doubting it, among the sectarians created 
by this great blessing: the varioloid, however, follows, and often in a violent 
degree; and though it is true, that experience is, as yet, in favour of the idea, that 
it prevents death, yet it produces a great deal of suffering; now, if upon the 
appearance of the varioloid, or the small-pox, in a country, those persons already 
vaccinated were again revacclnated, even where the original vaccination was 
perfect in all its stages, it is evident, that much pain might be obviated; and if^ 
further, after vaccination, we inoculated with the varioloid, premising diet and 
purges to prepare the system, little danger could be feared; whereas, according to 
the present belief, that the perfect disease is regular in its stages, and by it the pro- 
tection is complete, it is evident ,that there is great risk; vaccination, like all other 
form.s of cutaneous disease, is susceptible of various degrees, both in its progress 
from the smallest blush of inflammation, up to the regular vesicle; and there can 
be no question, that it is so also with regard to its protecting power; for we dis- 
cover every variety of varioloid after vaccination, from the mildest form v/ithout 
fever up to the most perfect small-pox; the belief, then, that vaccination, like all 
other forms of cutaneous affection, varies in degree, is the safe principle upon 
which to act witli regard to its protecting power. But, it is also supported by 
facts already observed; Bateman tells us, that though the irregular vesicles of the 
vaccine disease, describing three which bear that name, do not always protect 



• Llnd on Hot Climates. 
J Huxham. 
23 



1 78 THE EXANTHEMATA IN GENERAL. 

the system from the occurrence of small-pox,* yet sometimes they do, and that there 
may probably occur other irreg-ularities, and that their protecting- power may exist 
only to a certain degree: Even Dr. Bryce, who was attached to the certainty of 
the distinctions which are laid down for ascertaining" the true vaccine, states, after 
exhausting- his ing-enuity on this subject, that with reg-ard to the true affection of 
the constitution by vaccination, which protects the system from the small-pox, he 
knows no criterion but revaccination.f Thus neither is the most regular vaccina- 
tion, nor even its irregularities, to be exactly measured in their preventive power. 
This precise and mathematical mode of defining and measuring out the predispo- 
sitions of the system, and the phenomena which arise upon them by the action of 
morbid agents, in producing the endless variety and combinations of disease, leads 
to error, and is entirely incompatible with the true character of the system. 

"With regard to the statement, that the exanthemata are always inflammatory 
with the exception of scarlatina which is typhous in its character, it may be stated, 
that Dr. Kush describes the scarlatina of the years 1783-4, as exhibiting in some 
cases, inflammatory symptoms, and as requiring several bleedings. The pulse 
was hard; and the blood was covered with a bufly coat; these occurred in the cold 
weather.^: He says also, between the years 1793 and 1800, it was inflammatory, 
and required bleeding.§ This disease is, therefore, modified by season, as all other 
fevers arc, and exhibits in tlie autumn sometimes inflammatory symptoms. With 
regard to the general statement, that the exanthemata appear to be steady under 
almost every variety of circumstance, this also is not borne out. Dr. Withering 
states that the scarlet colour was kept up, in scarlatina, during the hot months, 
and that, when the air became colder, it nearly disappeared; that it was both less 
frequent and less permanent.!! He states, also, that those who lived on high and 
gravelly situations suffered greatly; whilst those in wet, low, or sheltered places, 
were hardly affected with the disease. The symptoms of this fever. Dr. Rush 
states, became less alarming towards October; the general fact, however, stated 
by Sydenham, with regard to these diseases, that they appear most commonly at 
particular seasons, shows that the state of the air has some effect upon them: thus, 
he says, that the small-pox usually begins about the vernal equinox; if violent, 
however, it appears in January: The measles appear in January, and increase till 
about the summer solstice, abating in the same gradual manner, till the same 
period next year: the scarlet fever, he states, usually appears about the close of 
summer; all these facts go to show that these diseases arc materially influenced 
by the seasons, and though the times of their appearance, as stated above, are by 
no means regular, yet they are sufficiently so to show that the opinion advanced 
in the text is not correct: 

Dr. Rush states that the measles of 1801 was strongly marked by remissions and 
intermissions, like the prevailing autumnal fevers :1T 

A cold and damp spring sometimes renders the measles, otherwise a mild disease, 
peculiarly fatal: Doctors Rush and Huxham** have both made this remark: Adults 
also died in greater numbers than the young people, in the epidemic described 
by Huxham, showing the effect of constitution on this disease. 



* Dr. Rogers and Pendleton, of New York, also state some further varieties, 
which still were sufficient to protect the system from small-pox; as the anticipation 
of the regular period of the vaccination, and its passage through them in a sliorter 
time: thus the mahogany scab M'as formed on the 8th instead of the 14th day, and 
vesicles, in which suppvn-ation takes place on the 3d or 4th day, the scab of a soft 
texture, resembling that formed in Porrigo, and.totally distinct from the dark maho- 
gany-coloured scab of the geiuiine cow-pox, and yet they were genuine and had the 
full preventive power: they also state, that the virus retained its virtue after being 
kept six ycarsjif showing that even in the qualities of the scab, which may be 
regarded as the last result of the inflammatory process, the small-pox does not 
diiier from the cow-pox in tlic long preservation of its powers. 

f JJrycc on Inoculation for Cow-l*ox, Appendix No. X. p. 114. Edit. 2d. 

+ Rush, vol. il. p. 410. 1809. § Ibid. p. 419. 

II Withering, p. 12. Lond. 1779. 

1 Rush, vol. iv. p. 117. 1809. ^ ** Ibid. vol. ii. p. 432. 

tt New York Medical and riiysical Journal, vol. i. p. 320, ct seq. 



THE EXANTHEMATA IN GENERAL. 179 

The measles, as described by Quier in Jamaica, affected the bowels principally, 
showing- the effect of the climate; in northern countries its tendency is always to 
the lung-s, the prevailing- character of diseases of tliose chmates; Like the fevers 
of Jamaica, also, the fever was disting-ulshed by remissions and intermissions; it 
preceded the eruption five or six days: Quier states that the measles also differed 
greatly, in different people, in the manner of its attack; the same author states, 
the most healthy were most frequently the subjects of it, whilst the delicate and 
weakly, escaped almost without any disease.* 

The same is true of the small-pox; it is inflammatory g-enerally as the author 
states; but it is much influenced in its character, by circumstances; thus in the 
epidemic of New York in 1823-4, it attacked principally those between the ag-e 
of twenty and thirty, and the poor; showing- that exposure and vicissitude, and 
streng-th of system have their influence; Its severity, it appears, was reg-ulated 
by the ag-e, habit and previous health of the individual. f The small-pox are 
sometimes of a low grade of action from the commencement; this is the case, 
where the pocks do not fill, or are ichorous or vesicular in their character. The 
state of the fever depends entirely upon the state of tlie system, when the small- 
pox invades it; if debilitated, the patient, even when inoculated, dies of typhus;^ 
There is nothing peculiar in the character of the eruption, to make it either in- 
flammatory or otherwise. These are important facts; depletion even in a strong 
person may produce typhus; and as in the weakly, typhus is often the result, it 
shows the impropriety of inoculating persons in that state. 

To suppose that the accession, the duration, and the violence of these diseases, 
are not influenced by external circumstances, is as unreasonable as to expect, that 
they would do equally well under all kinds of treatment: The weather, age, pre- 
vious constitution, are all circumstances, which increase or diminish the force of 
the motion of the heart, and of course must affect the disease. 

If the author means to state, that the fever in these diseases is steady and de- 
fined in its character under all external circumstances, always exhibiting the same 
symptoms, though they may differ in degree, this also will be found not to be 
true: Constant nausea and puking, was a prevailing character of the measles of 
1801, in Philadelphia: Its premonitory symptoms differ; Thus Dr. Quier of 
Jamaica, observed white apthous specks about the gums, visible several days be- 
fore the eruption, and before the patient is sensible of any indisposition; these 
specks spreading and increasing in size, at last extend down the pharynx; Ur. 
Hazeltine has also observed an eruption on the gums, previous to the appearance 
of the disease; Gum boils, and sores upon the tongue, have been observed by Dr. 
Rush. Toothach, epistaxis, deafness, tinnitus aurium, headach, coma, and' epi- 
lepsy have all been observed as symptoms of the fever. Affections of the lungs, 
from the slightest cough to the most violent pneumonia, both acute and chronic; 
a constant expectoration which proved fatal; also cynanche trachealis;§ also all the 
varieties of bowel affection, nausea, vomiting, diarrhoea and dysentery, in all its 
intensity.il The time of the attack from tlie exposure to the contagion, also 
varies; Withering generally observed it, after the third or fourth day's exposure to 
the infection; Rush, about the fourteenth, sometimes earlier and sometimes later: 

Dr. Rush also observed considerable variety in the time of the eruption, and 
in the abatement or continuance of the fever after it; in its colour being 
deeper, livid or pale, in the redness being equally diffused or in blotches, or in 
eruptions like the small-pox; the latter is also noticed by Cullen and Sauvages: 
In one case, the eruption remained for nine days, and disappeared without the 
branny scales, which usually follow it. 

The sequelae are equally various; Dr. Rush observed a fever of the intennittent 
kind, in another case, typhus mitior: a great variety of eruptions on the skin; 
porrigo, ecthyma, 8cc. also affections of the eyes, ears, and mesenteric glands, 
consumption, 8cc. Huxliam mentions diarrhoea, ulcers of the jaws, hectic, &c.^ 



* Quier's Account of the Measles of Jamaica. Lond. ir78. 

f N. Y. Med. and Physical Journal, p. 202. vol. iii. 

t Quier, p. 90. 1778. 

§ Rush, vol. ii. p. 425-6. 1809. || Ibid, also Quier on Measles. 

^ De Morb. Epid. vol. ii. p. 137. 139. 



180 THE EXANTHEMATA IN GENERAL. 

The scarlet fever is described by Withering", as exhibiting complete trismus, and 
something- like hydrophobia: These symptoms, with delirium, lieadach, coma, 
convulsion, and idiocy, which followed it, make up almost the whole round of 
nervous disease: He states also, that when the cold weather appeared in the fal], 
that pneumonic and intestinal symptoms became common in all their variety: 
Watson also describes dysentery, and even mortification of the rectum, as one of 
its symptoms: sphacelus in the lungs, also was discovered in another. 

A discharge behind the ears, and from the nose, with a shght eruption; a pain 
in the jaw, swelhngs behind the ears, and a slight f»ver; persons walking about 
till death, give an idea of the varieties of this malady, as they occurred to Dr. 
Rush, in the years 1783-4. With regard to the small-pox, we will say nothing 
farther here: Like all other diseases, it receives a character from the state of the 
system, and from external circumstances. As to these diseases, we, therefore, 
cannot agree with the author, that their course is either defined or steady, 
or that their character, in any one respect, is uninfluenced by climate, season 
and situation: Further, we beheve that in two different epidemics of either of 
these forms of fever, no two exactly resemble each other, and that experience 
only can determine the best mode of treating them, directed by the general doc- 
trines of fever, before delivered: To suppose that there is one regular undeviating 
train of symptoms, is to state what nature will not justify, and what the character 
of medicine cannot support. 

DEFINED CHARACTER OF THE ERUPTION. 

2. The second character of the exanthemata is drawn from their 
being attended with an eruption which goes through a regular 
series of changes. This is another of those remarkable facts in the 
animal economy, for which we may find some analogies, but which 
we shall never succeed ia explaining. The appearance of the erup- 
tion in each of the diseases of this class is peculiar, and except in 
some severe cases of chicken-pox, can hardly admit of any doubt. 
The progress of the eruption in each disease is also peculiar, but it 
is uniform. That of scarlet fever shows itself on the second day, 
and declines on the fifth. The eruption of measles shows itself on 
the fourth day, and fades on the seventh. The eruption of small- 
pox shows itself on the third day, and maturates on the tenth. 
To this regularity of progress in the exanthematous eruptions there 
are a few, and but a very few exceptions. In the inoculated small- 
pox the eruption is sometimes postponed from the ninth to the 
twelfth day; in the measles from the fourth to the sixth, or even 
later. The most remarkable exception is that enjoyed by the cow- 
pox, which has the characters of an exanthema without the occur- 
rence of any eruption; but the regular progress of the vesicle and 
areola are sufficient to entitle it to its present place in the nosology. 
Even this sometimes varies, for without any obvious cause the 
vaccine pimple occasionally remains dormant for four or five days, 
and is not elevated before the sixth or seventh day. These cases, 
however, are rare, and they only serve to teach us caution in 
framing our general positions. An inquiry into the course of each 
particular eruption will form a prominent feature in our account of 
the respective disease. The exact nature of the eruption is not 
always well understood, as in the case of measles and scarlct-fcvcr; 
but in that of small-pox it is genuine inflammation. 



THE EXANTHEMATA IN GENERAL. 181 

That the eruption, in these diseases, goes tliroug-h a regnlar series of changes, 
docs not exactly comport with the phenomena: 1. With regard to the small-pox: 
The small-pox, varioloid, chicken-pox, and vaccine, are varieties of the same dis- 
ease; witli regard to the small-pox and varioloid, this is pretty generally conceded, 
because they cannot be separated by any distinctive marks, and are mutually 
communicated by inoculation:* The varioloid and chicken-pox are also the same, 
differing only in degree; they run into each other by insensible gradations. The 
proof of this statement will, however, be given more particularly, under the head 
of modified small-pox: We may here mention, to connect the vacciife disease in 
this analogy, that inoculation with the matter of small-pox has produced the vac- 
cine disease in the cow, according to the experiments of Dr. Carpenter. Great 
varieties appear in the eruption: It sometimes, assumes the appearance of a single 
slight pimple, which never suppurates, but dies away in one or two days: This 
happens in the pocks of the varioloid; it happens in the small-pox, some of the 
vesicles of whicli are found to be small; it hajjpens in the small-pox, when inocu- 
lation is practised the second time, when often the pustule of inoculation does 
not suppurate, and yet will communicate the disease.f 

In all these cases, the pock occupies a small point of the surface, yet it is genuine: 
From this small point, which does not suppurate up to the most mature pustule, 
covering the skin from the breadth of half an inch to a universal bleb, which covers 
the whole surface, which runs its course in from one or two, to ten, fifteen, or 
eighteen days, the pock varies. The qualities of the contents, also, assume all 
varieties; they contain either water, bloody serum, or pus, in every degree, (as 
far as our senses inform us,) of which the local disease of the skin is capable: 
The eruption is, therefore, not regular: Besides, the fever of these exanthemata, 
is found without pustules, as in the variety mentioned by Sydenham; and thex'e are 
pustules, without fever, as in the single pocks, produced on the arms of nurses, 
(who have had the small-pox before,) from the contact of children, who have the 
small-pox; the pustules rise to various heights, are sometimes attended with fever 
and sometimes are not; and though they have not come to suppuration, and have 
not excited fever, they will communicate the disease: In general, the pox, result- 
ing from a second inoculation, after the person has had the disease previously, go 
through their changes faster, than inoculation for tlie first time; they are as far 
advanced by the third day, as the first inoculation is by the fifth; and are attended 
with general fever and pain of the axilla at times, and sometimes not; but they 
never rise so high, nor are so hard, nor is the inflammation so extensive in the 
second, as in the first insertion::): These facts show that these pocks (which, from 
their communicating the disease are genuine,) admit of degrees, and that the ap- 
pearance of variola is by no means regular; but has a most extensive range in its 
characters: 

It is so also in the character of the eruption; It is vesicular, and never sup- 
purates; or it is a compound of vesicles and pustules: The crystalline, in vi^hich 
the contents of the pock are watery, are always connected with typhus, § and it is 
owing to this low grade of action, that the fluid of the pocks is transparent and 
not purulent: Other eruptions are also produced by the fever of small-pox; as in 
the cases described by Sydenham, in which blebs, hke those of pemphigus, break- 
ing and ending in mortification; the disease was then highly inflammatory and the 
pemphigus appeared to be owing to this cause ;I| also a shining pellicle covering 
the pustules and secreting a bloody water; enough tlien has been said to show, 
that in small-pox every variety of pock with regard to size, number, extent, 
quantity and quality of the secretion, from water to the most mature pus, has 
attended this disease: 

Let us examine the measles: This disease is united with the character of the 
small-pox, by the appearance of pustules of small-pox interspersed with the erup- 



* See Dr. M'Nevens' paper on the Varioloid, N. Y. Med. and Physical Journal. 
p. 216. vol. 3. also Dr. Bell's, p. 207. vol. 3. 

f See Quier's account of the Small-pox at Jamaica, p. 77, 78. 
^ Quier's account of the Small-pox in Jamaica. 1778. Lond. 
§ Philip on Febrile Diseases, p. 387. vol. i. 
11 Rush's Sydenham, p. 229. Philadelphia. 



183 THE EXANTHEMATA IN GENERAL. 

tion of the measles, so as to g-ive rise to a species in the nosolog^^ of Sauvag-es, 
called the variolous; Cullen, Huxham, and others, acknowledg-e the same thing"; and 
Dr. Rush notices it:* It has appeared in one case, united with the varioloid eruption 
in Philadelphia this year: The local symptoms of measles, appear ^\ithan eruption 
which is distinguished by an efflorescence on tlie skin, in which there appears 
slight elevations, to be felt by the touch; these occur on the hands, wrists and 
fingers in the form of pimples, and sometimes, they are as large as miliary vesicles 
on the neck, breast and arms;f on the best authority then, the eruption of measles 
varies, from the most inconsiderable rising of the vessels of the skin not to be per- 
ceived, but felt, from a miliary vesicle, to a pock, like that of variola. 

With regard to the time of the appearance of the eruption, Philip describes it 
as occurring on the second, also on the fifth or sixth day, or later, and in the lat- 
ter case, of being- protracted till the twelfth, fourteenth, or twentieth day.t In the 
malignant measles, described by Dr. Watson, the eruption appeared on the 
second day,§ and it generally continued four or five days, and sometimes longer: 
Bateman says, it fades on the tenth: Dr. Rush states, in the measles of 178.3, the 
eruption usually began on the third or fourth. Sydenham in one epidemic, men- 
tions, that they appeared sometimes sooner and sometimes later than the fourth, 
whereas, in a former variety, they always appeared on the fourth: This last, he 
called a regular form, and as there have been but few writers on this subject since 
Sydenham's time, and as all appear to have copied that great man, the adoption 
of the fourth day for the appearance of the eruption in this disease, appears to be 
derived from him: There is, therefore, considerable variety from the second to 
the fifth days, in the time of the appearance of the eruption; Dr. Rush mentions a 
case, in which the eruption and fever occurred at the same time: Bateman states, 
that it appears on the third, fifth and sixth days of the fever, though usually on the 
fourth: The regularity of the period of the appearance of the eruption, is then by 
no means fixed: it will depend much upon the intensity of the fever, which, as in 
that described by Dr. AVatson, appeared on the second; in mild and moderate 
cases, it may be postponed till the fourth, but these cases estabhsh the rule, only 
for that peculiar class and not for all varieties of the fever. 

The scarlatina, which resembles measles so much as once to have been believed 
to be the same disease, sometimes appears with small red spots, broader, redder, 
and not so uniform as the measles: These, according- to Rush, appeared with con- 
siderable variety in 1783, 4; Sometimes it preceded and sometimes it followed the 
sore throat; in a few only it occurred on the second or third day of the disease. || 

In the scarlatina described by De Gorter, he states, that after three or four days' 
continuance of the fever the eruption appears; He states in general temis, that the 
term of their continuance is short: Morton mentions, that the scarlet eruption 
appeared on the fourth, fifth, or sixth day of the disease, and that it continued for 
seven, eight, or ten days:^ 

Sennertus describes it as appearing on the fourth or fifth day of the disease, and 
that it fades on the seventh or ninth day: In the epidemic scarlatina of Berlin, the 
rash also appeared on tlie fourth or fifth day.** AVithering- describes the eruption, 
as appearing on tlie third day,-|-j- and as abating in two or three days. These facts 
are sufficient to show, that tlie rash of the scarlet fever "is by no means regular in 
its appearance on the second day: Besides this irregularity in the appearance of 
this eruption, it is sometimes in the form of pimples, of vesicles, and even of pus- 
tules, which, in some cases, have been so distinct, as to give rise to a variety, 
termed the scarlatina variolosa, as seen by Sauvagcs, and a minor deg'ree of the 
same eruption, like the chicken-pox, as seen by Dr. Rush: 

Bateman mentions the existence of pimples on tlie breast and extremities; The 
appearance of these pustules in measles and sciulatina are rare; as the pustule is 
the result of the phlegmonous inHammutioii, whilst the action of the vessels in 
these diseases is generally so weak as not to amount to inflammation; These facts 



• Rush, vol. ii. p. 427. 1809. 

f Bateman, p. 57. Philadelphia edition, 1824. 



% 



hilip, p. 438, 9. vol. i. § Med. Obs. and Inquir. p. 139, 40. vol. iv. 



II Rush, vol. ii. p. 407. Tl Exercetat. 3. cap. 5. p. 53, 54. 

** Acta. Bcrol. Med. vol. i. p. 20. ft Withering, p. iv. Loud. 1779. 



THE EXANTHEMATA IN GENERAL. 183 

are sufficient to show that the local affection of these fevers is by no means 
reg-ular, either in the time of its appearance nor in its character; on the contrary, 
it is found to vary from the slig-htcst blush of the skin, as in those cases of scar- 
latina, in which there is almost no fever, or indisposition, to a pimple, a vesicle, 
and a pustule, in fact exhibiting- almost all the varieties of cutaneous inflammation: 
The position, in the text, is therefore not sustained. 

Here it may be said, that when a pustule appears upon the skin in scarlatina and 
measles, that it may be the result of tlie variolous poison, acting* on the system: 
it may be so; this is, however, hypothetical; the phenomena exist together, and 
•we are justified, in stating" them as varieties of these diseases, and more particu- 
larly so, as we see every day, that a slight degree of inflammation will produce 
redness; increase it, it becomes vesicular; increase it still further, pustular; if it be 
increased rapidly, the blisters are filled with bloody serum, as in pemphigus, and 
the cases of small-pox, quoted from Sydenliam: In fact, the whole history of these 
diseases convinces us, that they differ principally in degree, and that this is exem- 
plified by the state of the eruption, as well as by the fever, which exhibits all 
varieties from the slightest fever, or none at all, up to the most decidedly typhous 
or inflammatory form; and the local affection, from the slightest pimple to the 
most perfect pustule, and that all these varieties have appeared in each of the 
distinct forms of exanthemata, which the author has described as distinct diseases. 
It would, indeed, be easy to show from tlie author's own views, that these princi- 
ples are the only ones which can preserve him from inconsistency: Thus he states, 
speaking of Willan's arrangement of the varieties of cutaneous affection, that there 
is no possibility of separating them into different species, that they vanish into 
each other from the shghtest blush of inflammation to the most malignant pustule; 
this view is true; it is supported by the various changes of the exanthemata into 
each other: How then can he consider the local aflections of the exanthemata 
above mentioned, as different from those which appear in other forms? He con- 
siders the fever of the exanthemata to resemble continued fever, with the differ- 
ence of only the addition of an eruption: how then can they be separated in their 
various characters from these diseases? 

These views are important in a practical hght; they teach us to adapt our means 
to the case, and prescribe according to tlie symptoms in a rational manner; if, for 
instance, scarlatina is believed to be always a typhous disease, when it is some- 
times Inflammatory, and small-pox, and measles, always inflammatory, when they 
are sometimes typhous, the patient must suffer: 

This practice of imposing fixed definitions on phenomena which are variable in 
their nature, and whose changes the terms of the definition does not include, always 
leads to error and tends to enslave the minds of those, who think more by words, 
than by ideas; who piractise more by routine, than observation. It is easy, when 
the definition of a disease is laid down, to determine whether it belongs to the 
species or not; and after having laid down certain definitions, which embrace the 
whole ground, it is easy to show that the comm.on forms belong to them, but 
when we find nature varying infinitely, these nosological trappings must be laid 
aside as useless ornaments, and we must rest solely on the phenomena, which 
nature exhibits to guide us in our practice. 

THEIR OCCURRENCE BUT ONCE IN LIFE. 

3. The occurrence of the exanthemata to every individual once, 
and once only, in the course of life, is the most curious and charac- 
teristic feature in the history of these diseases. That every race of 
man, under every possible variety of climate, age, and constitution, 
should be susceptible of the same disease, that this disease should pre- 
sent every where the same character, and run through the same stages, 
and having once occurred, should never again appear in the same 
individual, though exposed to the utmost malignity of infection, are 
facts in the history of the animal economy, which may well excite 
our curiosity. The general accuracy is unquestionable, at least so 



184 THE EXAJ^THEMATA IN GENERAL. 

far as the constitution of the human body allows us to acknowledge 
any such widely extended proposition. 

EXCEPTIONS TO THIS LAW. 

Here, indeed, as in every other part of pathology, exceptions 
occur. A few constitutions have been met with, wliich appear to 
be completely insensible to the contagion of small-pox. Some 
individuals, who cannot be made to take the small-pox or scarlet 
fever at one age, are yet susceptible of it at another.* In like 
manner it is established on undoubted evidence, that small-pox 
and measles may occur twice in the same individual. Some patho- 
logists have refused to acknowledge the truth of this exception to 
the general law of the exanthemata, and have attempted to explain 
away the cases of secondary small-pox, by presuming on the 
ignorance or the carelessness of the practitioner in attendance. 
These and similar frivolous arguments do not admit of serious 
refutation. Such exceptions have undoubtedly occurred; and it 
is our business to watch nature, and not prescribe to her the course 
which she is to pursue. 

No doubt whatever can be entertained -with regard to the occa- 
sional occurrence of second and even third attacks of scarlatina. 
They are sometimes milder, sometimes severer than the primary. 

The occurrence of the exanthemata to every individual, once and once only, in 
the course of life, as stated by the author, though it is true, to a certain extent, 
yet it admits of more modifications, tlian he has embraced in the above remai'ks; 

1. With regard to the smali-pox; 

The varioloid, varicella, vaccine, and variola, are varieties of the same disease; 
and as the varioloid occurs in many persons who have had the small-pox, at every 
return of this epidemic, it is evident, that the position of the author, as far as 
regards the small-pox, that it can be taken only once during hfe is untenable; the 
small-pox it should be said is taken frequently; the author admits, that it can be 
taken twice; instances are recorded of its occurring thrice in the same individual, 
in its most violent form. But it is taken often in its moderate varieties; thus the 
chicken-pox, the varioloid, and the vaccine, are all taken after the small-pox. 
The true view of this subject, is, that the predisposition to the small-pox and all 
its varieties exist in ciulless degrees; thus it is generally acknowledged, that the 
vaccine renders mild and comparatively harmless the small-pox; that the small-pox 
exhausts, but not completely its own predisposition to return again immediately 
after it is passed from the system: this is proved, 1)y the occurrence of two suc- 
cessive crops of small-pox in the same case, in three days after the first, as hap- 
pened to Quier;t also by the inoculation of persons, who have had the small-pox, 
with small-pox matter; the inserted matter produces a pock which runs its course 
in a shorter time, and is sometimes attended with fever, but which can com- 
municate by inoculation the disease to another, whether attended with supi)uration 
in the inoculated vesicle, with swellings in the arm-pits and fever, or without; 
The varioloid disease, also, does not exhaust at once its susceptibility, for it, also, 
is followed by successive crops of i)ustulcs in the same attack, and so is the 
chicken-pox; when the disease ceases for that time, it shows that the suscepti- 
bihty is exhausted so far as not to be immediately reproduced by oidinary circum- 
stances of contagion, and as they both recur in the same individual afterwards, it 



• Iluxham. Treat, on Fevers, Small-pox, &,c. 
I Qtiicr's account, p. 82. 



r.r 



THE EXANTHEMATA IN GENERAL. 185 

is proof positive that it may be worn out, and recovered again : as the disease may- 
recur in the form of chicken-pox, varioloid, or small-pox, it shows also that when 
renewed it may also exist in every degree. 

The susceptibility for the small-pox, in different parts of the same system, is 
different; thus, we see, small-pox in full maturity, the crystalline, the horn-pox, 
running- their full course, whilst between the pustules, we find some smaller, and 
smaller, terminating in hard tubercles in one, two, or three days. 

The vaccine disease also, does not exhaust its susceptibility to a reproduction 
immediately: Like the small and chicken-pox, it is subject to a succession of 
eruptions, though it is a rare occurrence: Pendleton and Rogers saw a case, in 
which pustules appeared on the back and on the elbow of a patient, in whom the 
regular pock of vaccination had nearly come to its decline; Dr. Post, also saw a 
case of vaccination, in which vesicles going through their different stages, appeared 
on different parts of the body;* It is proved, also, that those eruptions, which 
occur, generally over the skin, after vaccination, have the power of reproducing 
tlie disease,! showing, that it is still the vaccine: These facts prove the necessity 
of a second eruption to eradicate the susceptibility^ 

Also, it has been ascertained by experiments, that re-vaccination, after the kine- 
pox has previously completely affected the system, will produce a considerable 
irritation, followed by a scab; a third and a fourth vaccination, is succeeded by less 
and less irritation, and smaller scabs, till the fifth has no effect; the scab, the 
result of a fourth vaccination, however, had the power of reproducing the disease 
in three instances; it retained its power, though it was not more than a line in 
diameter:§ Thus, then, it requires four vaccinations to exhaust the susceptibility 
of the system to this disease: It appears then from undoubted facts, that the small- 
pox has been communicated twice and thrice to the same individual, and that in 
general, the remaining susceptibility after having had it, admits of the varioloid, 
the vaccine, and the chicken-pox, all appearing in the same individual, and after a 
case of genuine small-pox, the inoculation with genuine small-pox matter, also takes 
so far as to propagate the disease from the inoculated pustule; and with regard to 
the vaccine, the same is true; the susceptibility to it is often exhausted by repeated 
vaccinations only: How then is it possible to say after the direct reproduction of 
these diseases after each other so frequently, both in the natural way and by 
inoculation, in the same individual, that it is a law that they can appear in the 
same system but once during a life: 

We have seen that the eruption of the measles, runs by insensible degrees from 
a blush, a pimple, a vesicle into the genuine small-pox pustule, and that in its 
fever, it is found in varieties from almost no fever at all, up to one that lasts for 
fourteen days; Running through these various degrees, we must conclude that the 
predisposition to its return also would exhibit the same variety, for the affection of 
the parts depends upon the degree of the predisposition: This is the fact: as the 
author states, it is taken more than once. Dr. Baillie records eight instances; Dr. 
Willan and Dr. Rush, saw also several. The true view of predisposition to the 
measles is, that it may exist in endless degrees; thus, the whole system may be 
susceptible of its influence, though the eruption does not appear; for cases are 
recorded, where the fever has taken place without the eruption ;|| and this fever 
may be accompanied by the eruption from the shghtest degi'ee, up to one which is 
most decided and strong: This fact has been observed by Dr. Rush: all the 
catarrhal symptoms with fever, diarrhoea and extremely sore mouth, were observed 
by him in the measles of 1773, without the eruption, except in some instances, 
when it was trifling. An author in the Edinburgh Medical Essays, mentions the 
same thing; he says, he saw the fever and all the other symptoms of measles with- 

* New York Med. and Phys. Journal, vol. i. p. 320. f Ibid. p. 113. 

■^ Vaccination also sometimes produces death; Dr. Rogers and Pendleton, men- 
tion one case, in which this result took place by the extension of the erysipelas 
over the body: Woodville also records one Instance :t It also analogises with 
small-pox, &c. in eradicating other maladies, as crusta lactea, ophthalmia, scrofula.** 

§ Dr. Darrach's Experiments, in Philadelphia Journal for 1824. 

II Philip, vol. i. p. 442. 

T New York Med. and Tliyj. Journal, vol. i. p. 320. •» Ibid. p. 115. 

24 



1S6 THE EXANTHEMATA IN GENERAL. 

out the eruption:* this partial appearance of the symptoms occurred without the 
predisposition being" exhausted, for the last author mentions, that the same person 
had the disease months or yearsf afterwards^ Dr. Rush farther mentions, that in 
1789 he saw all the other symptoms of measles with a small and trifling" eruption 
about the neck and breast in some cases only:§ Sydenham also saw the eruption 
on various parts of the body, without first affecting the head and breast, and 
coming- out irregularly; and the fever so slight as not to end in scales :|| The irregu- 
larity of the eruption shows that the fever was weaker in its tendency to the skin, 
as also does the absence of scales: The fever- only may be present, or it may be 
attended with an eruption varying in degree; the predisposition must also vary in 
these respects: according^, in some, the disease has been kept off by these partial 
affections for months, in others for years, as we have stated above: 

Sometimes, a second fever and eruption takes place after the first has disap- 
peared, showing that the predisposition was so strong, that one attack was not 
sufficient to overcome it. Sometimes the eruption appears without the catarrhal 
symptoms, and when it declines, a second eruption appears with violent disorder 
of the constitution, t showing as above, the various nature of the predisposition, 
that it is not exhausted by one attack; sometimes (as in inoculated small-pox, 
when there is no fever and no pocks but the one produced by the inoculation,) 
the measles appears with local symptoms only, without fever or general eruption; 
in fine, so various is the predisposition, that the fever appears of all grades, from 
the mildest and hardly perceptible degree up to the most severe, ending in 
peripneumony, coma, convulsion, dysentery, spasm, and gangrene of the rectum, 
&c. the same thing has been shown of the eruption; it occurs from the mildest 
blush up to the most perfect pustule: and after the most mild, as well as the most 
violent forms, the disease has reappeared;** With regard to scarlatina, the same 
thing may be observed. 

1. It is taken twice and three times by the same individual. This, it is true, 
has been denied by the most respectable authority: Our author states under the 
head of scarlatina, that it is taken even twice or thrice by the same person; 

The susceptibility varies in the same manner in scarlatina, as in the preceding 
diseases; It varies in the character of the eruption, from a simple blush without 
and with red points, ff pimples,^ watery vesicles,§§ to pocks like chicken-pox;|lI| 
The latter variety, called the scarlatina variolosa, has been noticed by Sauvages, 
as stated above: 

Scarlatina in its susceptibility, resembles the small-pox and measles; for such 
persons as have previously had this fever without the sore throat, have taken the 
sore throat and had no eruption, whilst those, who had previously the sore throat, 
have a scarlet eruption, without any affection of the throat.^ ^ The fever, also 
occurring in every possible degree, shows the various susceptibility of the system 
to the operation of tlie poison: Indeed, it is said, that cold alone produces scarla- 



• Philip, vol. i. p. 442. f Rush, vol. ii. p. 428, 9. 1809. 

t It may be said, that this fever was not the fever of tlie measles, but a prevailing 
remittent: Dr. Rush puts this beyond question, by observing, that, 1. He never 
saw it affect any but children, in the degree that has been mentioned, and such only 
as never had the measles: 2. It affected whole famihes at the same time, and 
proved fatal. 3. It ended in a pulmonary consumption in one case, with the 
symptoms, which attend tiiat disease, when it proceeds from the measles. 4. 'It 
affected a child in one family on the same day, that two other members of the 
same family were affected by the genuine measles. 5. It appeared on the usual 
days of the genuine measles, from tlie time the persons effected by it were exposed 
to its contagion; and 6. It communicated the disease in one family in the usual 
time the disease is taken from the genuine measles. 

§ Rush, vol. ii. p. 428. || Sydenliam, p. 377. Lond. Ed. 1676. 

U Willan on Cutaneous Disorders, order iii. parti. 

•• Baillie, Transactions for the Improv. of Med. and Chir. Knowledge, vol. iii. 
p. 258—63. 

■j-f Withering, p. 5. 1779. Rateman's Svnopsis, p. 69. Philadelphia, 1824. 

n Ibid. §§ Withering, p. 116. Plenciz, quott-d by him. Ibid. p. 42. 

nil Rush, p. 411. vol. ii. t1 Hush, vol. ii. p. 430, 1. 1809. 



THE EXANTHEMATA IN GENERAL. 187 

tina; Withering mentions, that persons after eating- oat meal, muscles, (musculus 
edulis,) and sweet almonds, "are sometimes affected with a scarlet irritation of the 
surface resembling" scarlatina.* There is another circumstance, which separates 
the exanthemata from other fevers in the minds of many medical men; It is, their 
not requiring" exciting" causes, as cold, fear, fatigue, &c. to bring them into action, 
as common fever does; This may be in some measure true. As to scarlet fever, 
however. Dr. Rush found that a purge prevented its appearance, after the 
person was exposed to its infection, as it does common fever; Ur. Sims had made 
the same remark; vomits also completely checked it in the forming stage,f which 
shows that tlie operation of its causes as in common fever, can be abated, and of 
course, if in their stead stimulating agents had been applied to the system, a con- 
trary effect might have resulted: Small-pox and measles are both mitigated by 
diet, &c: The subject is yet in its infancy. Though these diseases are without 
doubt possessed of a character of wearing out their susceptibility to return, yet 
this we believe to be much less than has been imagined; as soon as they have been 
examined with the same scrutinizing eye, as small-pox, this position will be more 
generally maintained: and more particularly when it is considered, that since 
Sydenham, there have been but four or five original writers on measles; and that 
the other diseases of the class have also been observed with an attention equally 
general. 

Attempts have been made by pathologists, to explain the causes 
to which secondary attacks of the exanthemata are to be referred. 
Sir Gilbert Blane believes, that the first attacks are always, or 
nearly always severe; and he argues, therefore, that the secondary 
attack is owing to the susceptibility of the constitution to the dis- 
ease being in such individuals stronger than in others. Dr. Wells, 
on the other hand, apprehends, that where a secondary attack 
occurs, the first will be found to have been mild; that the suscepti- 
bility therefore is not greater in these cases than in others, but that 
the primary attack had not been sufficient to saturate, as it were, 
the constitution. The phenomena of modified small-pox, ^yhich 
have lately attracted so much attention, hinge upon this question. 
Perhaps it will be found, that neither of these explanations is 
altogether satisfactory, and that the occurrence is attributable to 
some peculiarity in the constitution of the individual the precise 
nature of which does not admit of being developed. 

THEIR ORIGIN FROM SPECIFIC CONTAGION. 

4. The last feature in the general character of the exanthemata 
is their origin from specific contagion. I have already (page SO) 
explained the difference between the several kinds of contagion, 
and pointed out a few of the most important principles involved in 
the doctrine, more particularly such as relate to the operation of 
common contagion, and are subservient to tlie pathology of fever. 
An origin from specific contagion is a character of eruptive fevers, 
but they possess it in common with many other diseases — the 
plague, psora, syphilis, and hydrophobia. It is this character 
indeed which associates the exanthemata with that tribe of diseases 



* Withering, p. 62, 3. Lond. Edit. 1779. 
t Rush, vol. ii. p. 419. Ed. 1809. 



1S8 THE EXANTHEMATA IN GENERAL. 

which have been designated by the title of the morbid poisons. 
This phrase has been invented to distinguish these disorders from 
such as arise from mineral or vegetable poisons, or the exha- 
lations of marshes. It is supposed that the poison in all the dis- 
eases now alluded to, is produced from an animal body already in 
the state of disease, and therefore it is called a morbid poison. The 
plague has been considered by some authors as an exanthematous 
disease, but we have elsewhere given our reasons for believing that 
it is more nearly allied to the typhoid fevers. The yaws or fram- 
boesia is a peculiar disease, which arising from a morbid poison, 
and running a defined course, may perhaps be admitted into this 
class. 

That these diseases also require a peculiar state of surrounding" circumstances 
to concur in their production, is certain: They will not spread only at certain 
seasons; if they are introduced they die away; a case of varioloid of the most 
decidedly dangerous character, occurred at West Point some years ago; it was the 
only one, among many families; no person had visited the place with the disease, 
and it ceased with that single case; where did it originate? From the air? Huxham 
observes, that the small-pox ceases, unless there is a state of the air favourable to 
it:* The fact, that the disease dies in certain seasons, when introduced, and 
always, even when most epidemic, shows that some other circumstances are 
necessary than simply the infection: The idea that it arises only from a small por- 
tion of matter inserted into the system, without taking into view the predisposition, 
has had a pernicious effect on the practice: Purges, no doubt, prevent the scarla- 
tina; and as the small-pox, measles, &.c. are of all types, dependent upon the state 
of the system, which arises partly from the air, it is clear, that in our preparation 
for these maladies, we must be much regulated by something more than the dis- 
ease, to avoid the contagion arising from the virus: external circumstances have 
much to do with it: The rules for the treatment and preventioR of common fevers, 
without doubt apply equally to the exanthemata. C. 



PECULIARITIES OF SPECIFIC CONTAGIONS. 

Of the nature of the specific contagion in each of the exanthe- 
matous diseases, we are completely ignorant, and the subject is 
altogether inscrutable. It is quite clear, however, that it is some- 
thing of an exceedingly subtile nature. A single vesicle of cow- 
pox contains sufficient of the specific matter of contagion, to com- 
municate the disease to an incredible number of persons. A single 
drop is sufficient for each, perhaps a small portion of a drop, and of 
that there is reason to believe that the bulk consists of the common 
serum of the blood. The multiplication of this morbid poison in 
the body of the affected individual, is wholly inexplicable. The 
older physicians applied the analogy of vegetable ferments to the 
explanation of the phenomenon, and certainly with much ingenuity. 
The doctrine of a m^atcries morbi is satisfactorily proved in the 
case of small-pox, cow-pox, and syphilis, and the old humoral 
doctrines have doubtless therefore some foundation in nature. 
Whether they can be extended so as to explain the phenomena of 



• Huxham, p. 14. yol. i. 1788. 



THE EXANTHEMATA IN GENERAL. 139 

some corresponding affections, and perhaps of certain others whose 
pathological relations are not so obvious, may in future times 
become an object of inquiry. 

The author in speaking- of the inscrutable nature of the contagion of cxanthe- 
matous diseases, brings up the old doctrine of essences, as if the nature of a body 
was something different from the quahties it exhibits: Every natural object is to 
be known, only so far as it is cognizable by the senses, and no farther, and the 
information, thus obtained, or the phenomena are all we know or can know; and 
when we note down what we see, we do all that can be done. Beyond it there is 
nothing to be known; the doctrine of the essences of things, as it leads the mind to 
speculate beyond the phenomena, or actual qualities of bodies, has done much 
harm, by leading to idle surmises and theories. Not contented with knowing all 
that can' be known, we invent more and fill the science with error. The exanthe- 
matous fevers, their contagion, and all their other properties are to be known only 
by the observation of their sensible appearances: Farther, they are as inscrutable 
as gravity, magnetism, electricity, or any other principle. C. 

The exanthematous contagions were for a long time confounded. 
Small-pox and measles were for many centuries believed to arise 
from the same contagion. The measles and scarlet fever were 
considered by Morton to be the same disease, nor was the diagnosis 
clearly established until lately. Some pathologists at present 
believe there is an affinity between the contagions of small-pox 
and cow-pox; and within the last few years, the notion of the 
identity of small-pox and chicken-pox has been revived. The 
origin of all these contagions is involved in obscurity; but though 
we cannot form the most distant idea how they first got into the 
world, we can yet in many instances trace, with some precision, 
the periods when they first began to spread as epidemics. It is a 
very remarkable circumstance, that the exanthemata, and the seve- 
ral morbid poisons associated with them, were unknown to the 
ancient physicians, and did not appear in Europe till after the birth 
of Christ. To ascertain the countries in which these diseases 
originally appeared, and from which they were propagated over 
the rest of the world, will prove an interesting subject of investi- 
gation. 

The diagnosis of small-pox and measles, was not attempted till the year 1785, 
by Heberden; some doubts, we think, may still reasonably be entertained on the 
propriety of the absolute distinction of these diseases: it is certain, if we take as a 
principle, that the measles in their regular form, observe certain periods, it is easy 
to find examples to bear us out in the position: but when we find other varieties 
as above stated, in certain seasons, equally common, we must say that nature does 
not always act in one uniform manner: They vary according to the predisposition, 
constitution, &c. Heberden states, that "the measles and scarlet fever sometimes 
resemble one another so much, as not to be readily distinguished; though this be 
a matter of importance, because the method of cure is different:"* to this we 
reply, that scarlatina is treated by the same active depleting measures, that are 
generally useful in measles, as before observed; and that measles are best managed 
in some cases by the supporting plan; for instance, Huxham mentions in his work 
on air and epidemics, the measles as occurring with petechias and sudden prostra- 
tion: The state of the system, it is evident, must do much to determine the nature 
of the fever, whether typhoid, typhus, or otherwise, and of course the treatment: 



Medical Transactions, vol. iii. p, 396. 



190 THE EXANTHEMATA IN GENERAL. 

it is, therefore, idle to consider the symptoms enumerated generally, under the 
head of measles, as always indicating" a particular treatment; thoug-h it may be 
generally true, that when the thorax, eyes, and the higher degree of redness of 
the skin, which attends measles may require the antiphlogistic plan more generally 
than the scarlatina, which is distinguished by a less degree and which occurs most 
commonly in the autumn, after the depletion produced in the system by the 
abstraction of heat, when a typhous disposition is more prevalent. 

The cough, watery eyes, the eyelids red and swelled. Dr. Heberden says seldom 
fail to attend the measles. We learn, from Withering, that the eyes and nostrils 
in scarlatina are red; this is produced by the tendency of the blood' to the head, as 
the delirium is high in proportion; besides, the measles, sometimes come on with- 
out the above symptoms; The phenomena, occur in various degrees, as before 
observed; Dr. Rush saw during the prevalence of the scarlet fever, sudden swell- 
ings of the eyelids continuing for two or three days; inflammation of the eyes, with 
sudden swellings of the lips and throat, continuing also about the same time;* 
Heberden says, " the time, likewise, of the eruption is diflTerent in the scarlet 
fever; it appears both on the face and arms, on the first and second day, but in the 
measles, it begins only on the third day of the fever to be visible about the chin, 
and does not come to the arms and hands, till the fourth or fifth day; and does not 
usually consist as in the measles of distinct spots, with the natural colour of the 
skin interposed." 

The eruption of the measles sometimes appears on the second day of the fever, 
and disappears on the fourth. In the form described by Dr. Watson, this was 
generally the case: It does not appear sometimes till the fifth day or later, and 
then it is protracted to the fifteenth or twentieth, as remarked under the head of 
measles: The fever of measles has appeared in the typhous form and ended in 
death without any eruption. f The eruption in the measles does not always begin 
about the chin, as in the fever mentioned by Sydenham ;t but on various parts of 
the body; Dr. Heberden says, that the eruption of the scarlet fever does not 
usually, as in the measles, consist of distinct spots with the natural colour of the 
skin interposed; Bateman describes the eruption of the scarlet fever, (simplex,) 
as being formed of redness, coalescing into small patches, on the second day; on 
the third, as exhibiting a diffuse redness over the limbs; on the trunk, however, 
he says the rash is seldom universal, but is distributed in diffuse irregular patches, 
&,c. and when it disappears on the fifth, these patches occur again, with interstices 
of whiter skin between them: How then are these authors to be reconciled? 
Heberden speaks of the uniform redness of the skin, as a distinctive trait of scarlet 
fever; Bateman describes it as beginning and ending in patches, over the whole 
body, and when at its height on the trunk, never exhibiting this uniform colour; 
Bateman describes the scarlatina anginosa, as coming out in scattered patches 
only: Heberden uses the expression the scarlatina does not usually consist of 
spots, which shows, that he did not rely implicitly on this character: These objec- 
tions are stated as rendering it probable that these diseases run into each other 
by degrees, which cannot easily be defined: Dr. Rush mentions a diffused redness, 
as occurring in the measles of 1789, instead of the eruption; in others, he says it 
occurred in blotches;§ These distinctions are, therefore, not universal; They may 
occur frequently; but they cannot be considered as by any means breaking the 
general position, that these diseases run insensibly into each other, and cannot 
easily be distinguished in their remote varieties: These remarks will have the full 
effect intended by the author, if they put the reader on his guard to treat these 
diseases according- to their true ch:u'actcr, without respect to their place in the 
nosology; and not to expect always when the skin is uniformly red to find a 
typlious disease, nor when it exhibits these gradations of symptoms, which appear 
under the state of system called measles, to find an inflammatory diathesis: it may 
be often the case, but it is not by any means always so; There are few records! of 
these diseases; and still fewer of the varieties of their symptoms, and the subject 
is one which is worthy of investigation. 

* Works, vol. ii. p. 416. 

-}■ Ed. Med. and Surgical Journal, p. 123. 1817. 

1 Svdenham, ]i.37r. I.ond. Ed. 167(>. 

§ Works, p. 'V27. vol. ii. IHOD. 



THE EXANTHEMATA IN GENERAL. 191 

COMMUNICATION BY INOCULATION. 

Among the peculiarities of specific contagions, communication 
by inoculation has been mentioned. This however is not a general 
law. Measles, chicken-pox, and scarlet fever, cannot be given in 
this way; and the remaining diseases of the class share this pro- 
perty with several other affections, — syphilis, gonorrhoea, psora, 
and Egyptian ophthalmia. The uniformity in the latent period 
of most of the specific contagions^ whether febrile or chronic, de- 
serves some notice in a general view of the pathological relations 
of the exanthemata. It'appears to be often as accurately defined 
as the periods of the fever, and this by an unknown law of. the 
animal economy. It admits, however, of some variety, though 
apparently not so great as in the case of comtnon contagion. The 
latent period of typhus for instance, is considered to vary from a 
week to two months; that of small-pox and plague certainly does 
not vary more than a few days. 

It has been always reckoned a very striking feature in the his- 
tory of the exanthemata, that they are not compatible with each 
other, or with any other disorder. In most cases, if another dis- 
ease be present, the exanthemata will not advance. Thus diarrhoea 
and fever prevent the success of inoculation. Eruptions on the 
skin retard and modify the appearances of the vaccine vesicle. 
Cases have been mentioned, where the small-pox and measles 
occurring together, the small-pox has been delayed, until the latter 
has run its course.* This law however is subject to numerous ex- 
ceptions. It has been proved for instance, that small-pox and 
measles, as well as cow-pox and measles, may co-exist. Measles 
and hooping-cough frequently proceed together." In like manner 
small-pox and cow-pox are sometimes observed to advance, each 
vesicle preserving its own character. The principle, nevertheless, 
is an important one; and it may perhaps be illustrated by the well 
known fact, that during the prevalence of an epidemic plague or 
yellow fever, (the one notoriously, and the other very probably 
arising from specific contagion,) all other disorders disappear. 

The incompatibility of eruptive fevers as a general principle is true, but the 
exceptions we frequently meet with, constitute a curious and difficult problem in 
patholog'y. We have nevertheless often observed, that the contag-ioii which 
makes the first impression on the nerves, maintains its ascendance, till it shall have 
run its ordinary course, either superceding- or retarding- that which immediately 
succeeds it. This effect seeips to be in the ratio of the distance of time, between 
the two morbid impressions. It would seem probable, tliat every specific poison 
exerts a peculiar influence on some series of org-anic life, different from every 
other, and hence the actions they excite may exist, at least separately, if not 
independently. Eruptive fevers not only suspend other diseases, but eradicate 
old predispositions. Measles cure pertussis and intermitting- fever, which cease 
at the completion of the eruption. Tliey remove the predisposition to chronic 
rheumatism and sometimes cure it. They obliterate the predisposition to tra- 
cheitis in some children. The same effects may be observed after the small-pox, 

* Edin. Med. Comm. vol. iii. p. 443, also vol. i. as quoted by Thomas. 



192 THE EXANTHEMATA IN GENERAL. 

especially when the eruption has been copious: all these tilings we have observed 
in our own practice. 

The examples of plague and yellow fever adduced by the author, are unfortu- 
nate specimens, even viewing it in an analogical light. The fact so long noticed 
by Diemerbroek is undoubted, but it admits of a rationale the reverse of the 
hypothesis in the text. It is not the actual existence of the plague or yellow 
fever in the living body that repels all other causes, because othei-s living in the 
same place, not exposed to the sick, would be equally as susceptible to any other 
cause, as they would be in other situations. The explanation is easy. Both the 
proposed illustrations are derived from an inquinated atmosphere in which alone 
their causes reside. This opinion has been confirmed by hundreds of examples, 
as it regards the yellow fever, and will be found not less philosophical as it respects 
the plague. While the plague prevailed with great mortality at Bucharest, in 
1816-17, many of the inhabitants sought refuge in the neighbouring mountains; 
some of them experienced the disease after their removal, but it was not propa- 
gated to their household. Neither wives, husbands, children, nor attendants were 
afflicted with plague. Those who received the remote cause previous to their 
removal, were the only sufferers. Atmospherical infection is one thing; contagion 
another. The last is always animal, the other never. P. 



In Dr. Willan's arrangement of cutaneous affections, it will be 
found that the natural connexions of the exanthemata are broken, 
and these diseases thrown into other pathological relations, to which 
they do not appear to have any claim. This has been done under 
an idea that there is some essential difference between a pimple 
and a rash, a vesicle and a pustule. These I believe to be little 
more than modifications of each other, and by no means so distinct 
as to become the foundation of nosological arrangement. The 
same disease is vesicular at one period, and pustular at another. 
A slight accident may at any time convert the vesicle into a pustule. 
Indeed, as a general principle in pathology it may be stated, that 
the pustular or vesicular character of an eruption depends upon, 
and is determined by, the quantity of inflammation existing in the 
cutis, and the degree of strength in the general system. Upon the 
whole there can be little doubt, that Dr. Cullen's classification of 
the exanthemata, is pathologically more correct, and in practice 
more applicable, than that suggested by Dr. Willan; and we shall 
follow it therefore in the subsequent pages. 

THEIR CONNECTION W^ITH DISEASE OF THE MUCOUS MEMBRANE. 

The pathology of the eruptive febrile diseases is confessedly as 
obscure as that of the simple fevers; but latterly an attempt has been 
made to clear up some of the difficulties in which it is involved, by 
showing, that disease of the great mucous membranes of the body 
is implicated in them, as intimately, and to almost as great an extent, 
as the skin itself. * The structure and functions of the skin and 

• The sympathies seem easier produced in parts similarly organized than in 
others. The quick ciu-rcnt betwixt the skin and intestines is very remarkable, in 
the effects of diminished perspiration in exciting diarrhoea, dysentery and some 
other diseases. It seems to be on this principle we may explain many of the 



THE EXANTHEMA 1 A IN iiENERAL 193 

mucous membranes bear a close resemblance to each other, and 
many pathological considerations tend to prove that there exists 
also a very close analogy in their diseases. It would be a ra- 
tional conjecture therefore that in fevers where the skin is ex- 
tensively concerned, the mucous membranes would participate, 
and observation favours the opinion. The principle appears tu 
be of very general application, and is illustrated not merely b^ 
the symptoms which the different exanthemata present in theii 
different stages, but by the appearances also found after death. 
There is reason to suspect, that upon this intimate connexion be- 
tween the exanthematous fevers and disease of the mucous mem- 
brane, depend several of the most important varieties and anoma= 
lies which have been observed; such, for instance, as the reces 
sion of the eruptions, and the occasional recurrence of the disease. 
As we proceed in the separate examination of the diseases of this 
order, we shall have frequent occasion to refer to these, as well 
as to the other general views of the exanthemata which have been 
taken in this chapter, and which, though avowedly obscure, may 
yet give us some assistance in explaining their several phe- 
nomena. 

It is difficult to imag-inc iiow tlic connexion of the mucous membrane v.ith 
tliese diseases can throw any light upon their patholog-y, their varieties, anoma 
lies, or occasional recurrence. The connection of the lining" membrane of 
bowels and the skin, and the disposition of these maladies to aiTcct both these, 
surfaces, has always l)ecn acknowledged^ the phrase mucous membrane, wliich 
(ills now the mouth of the profession, discovers to us no new phenomena; they 
are the same, and no new turn of expression can chang-c them; it is a barren 
source to look for explanation of wliat cannot be explained; further tlian the 
succession of the phenomena, we observe notliing*, nor can know any thing*. 

It was this last circumstance in natural philosophy wliich led Newton to the 
great results which distinguish his life, and not the idle investigations about 
the intimate antl essential nature of causes, as of gi*avity, Sec, which begin in the 
imagination and end in notliing. The talk about the division of membranes, 
and the accurate location of certain diseases in them, is the folly of the day; il 
occupies the place of tlie lentor and the spasm of the days which are passed, 
and we believe with as little prospect of advantage in unveiling' the secrets of 
natiu-e. The opinion of CuUen, that the serous membranes are rarely aftcctcd 
without tlie contiguous structure partaking in the diseased action, is one which 
the morbid phenomena renders certain alter death, as well as the generrJ in- 
creased action of tlie blood-vessels during- life, which are in the plileg-masize ex- 
cited not partially but in every part of the body: that the blood-vessels can act 
more strongly on the surface of a membrane as thin as tlie peritoneum or pleu- 
ra, without tliat action extending beyond it, is unreasonable, particularly as the 
great power which sets the blood in motion, is increased in its action; how 
common is it to find even the skin of the surface of the belly in peritoneal in 
Hammation so tender that it cannot be touched; the same is true of inllamma- 
tions of the chest, and of Uie head. How common is it to see inflammation ol 
the brain involved in that of the scalp, periosteum, bone, dui-a mater, pia mater, 



metastasis of fevers. Many allcctionb of Ihc stomach would illustrate tliis po- 
sition. The connexion between a diminished cutaneous secretion and the 
aggravation of dyspeptic symptoms is very rcmarkablo. 

Vol. II.--25 



194 THE EXANTHEMATA IN GENEUAL. 

witli an abscess below, and all the results of a slig-ht blow on the surface of tlie 
head but little regarded, ending" at last in palsy, epilepsy, &c. So it is with 
tlie inflammation of the lungs, liver, &c. The peripneumonia, paraphrenitis, 
which confined the inflammation solely to the covering membranes of certain 
organs, have long since been thrown aside, because the organs tliemselves are 
seldom found uninflamed when the substance of tlie viscus is so. 

But gi*antitto be true that inflammations reside only in pailicular structures 
in the same attack, the phenomena of measles or small-pox are not better ac- 
counted for, because the structures they are supposed to be seated in have tlie 
power of secreting mucus or any other substance, or because they line the ali- 
mentary canal, or any other structure. The phenomena are still tlie same as 
they were in the days of Cullcn; the diarrhcca, inflammation of the bronchia 
in measles, &c. are the same they always have been: their more accm-ate ob- 
servation, varieties, and classification, only should occupy us, so that they may be 
more completely relieved by the discovery of their relations, and of proper 
remedies. We subjoin a few general remarks upon these diseases, wliich 
should have come in at another place. 

These diseases all constitute one family; there is some reason to believe 
that they generally appear about the same time. Withering states tliat the 
scarlet fever appeared about the same time with tlie small-pox, measles, and 
hooping-cough: the ulcerated sore-throat preceded it. Navier states tliat sciuiet 
fever succeeded the small-pox ; Morton observed tlie former to prevail with the 
measles,- Sydenham states that the scarlet fever succeeded the measles; also 
that the measles introduced the small-pox of the years 1670 and of 1674. A 
variety of erysipelatous fever, which, like the scarlet fever, came on towards 
the end of summer, appeared with it in one epidemic constitution: this erysipe- 
las was distinguished by great pain and redness of the skin, which was cover- 
ed with regular rows of very small pimples, resembling somewhat the stings of 
bees, and ending in vesicles: tlie fever preceded a day or two. He describes 
another species, sometimes ending in vesicles resembling the stings of nettles, 
receding in the form of tubercles in the skin, attended with a most violent and 
intolerable itcliing, establishing the affinity between erysipelas and urticaria, 
as the former species does between scarlatina and erysipelas. In Pliiladelphia 
the fever of tliis year (1828) is distinguished by affections of tlie skin, urticaria, 
erysipelas, measles, and varioloid; tlie two latter, in one case, appeared toge- 
ther: that they arc necessarily connected in their appearance, the above few 
exti-acts are not advanced as being suflficient to prove; they may, however, 
lead others to investigate the subject. But the following facts will show tliat 
the exanthemata are more intimately united witli Uie diseases of tlic skin 
generally than has been commonly imagined. 

A former attack of measles is sometimes followed, not by measles, but ery- 
sipelas, ending in urticaria,* with tlie fever and the other symptoms of measles, 
cough, sore eyes, &.c. The variety of aftections of the skin, which, during an 
epidemic, take the place of small-pox, in those formerly attacked, bears very 
strongly upon this point. Thus, tlie fever of the small-pox appears in many, 
and is succeeded by certain eruptions, and the small-pox docs not appear. 
These are a rash resembling the first eniption of the small-pox, spread all over 
the skin; another with the character of measles; a nettle rash, which ends in 
erysipelas, with great heat and itching of the skin, all appearing in ])crsons 
who have already had the small-pox,j- and introduced by a fever rcscnii)llng 
that of tliis disease. These facts would seem to show that the local aflcctions 
of these diseases had something in common with other affections of the skin, 
and that the structure, like every other part of the body, is susceptible of a 
certain range of morbid phenomena, connected with fever and without; some 
of which have a greater and some a less tendency to recur in the same indivi- 



* Ed. Mod. Essays, vol. v. p. '28. 

j Quitr's account of the small-pox at Jamaica, p. 77, 78. 



THE EXANTHEMATA IN GENERAI.. 195 

dual, l)Ut how often, and what cu-cumstanccs vary this tendency, tlie science 
has not as yet thrown sufficient Hg-ht upon the suljjcct exactly to determine. 

Further, it would appear from an examination of the records of mortality 
made in Glasg-ow, by Dr. Watts, that the mortality formerly produced by sniall- 
pox, is now occasioned by the measles; the small-pox being' disarmed of its 
terrors by vaccination. This is an impressive fact; it shews that there is a 
certain degree of predisposition to reaction in Hie skin, which must be ex- 
hausted by some of its eruptive diseases. 

Huxham asks this question in his book on Air and Epidemic Diseases: " Is 
there not some peculiar disposition to produce cuticular eruptions? Surely 
at the same time that the small-pox and pustular fevers arc rife, all kinds of 
eruptions, as tlie rash, erysipelas, 8cc. are common, as is very frecjuently ol)- 
served; nay, it hath been long- and commonly known, even among- old women 
and nurees, that the measles and swine or chicken-pox, are very often har- 
bingers of the small-pox."* The usual records of tlie occurrence of epidemic 
diseases arc so general tliat thoug-h some of tlie exanthematii may appear, the 
minor forms of them may not be noticed: the subject is important and de- 
serves investigation. 

This view throws it open to an inquiry very interesting to mankind: What 
are the various agents which are most favorable to the extinction of this sus- 
ceptibility in the skin? What are its sources; the aii*, &c.? It is proved by the 
foregoing facts, that even small-pox itself does not eradicate completely, only 
after several inoculations, the disposition to the recurrence of the disease; 
and after it has worn out its susceptibility for the small-pox for that time, 
other eruptive diseases appear at the same time witli the fever of the prevail- 
ing disease of the skin. 



* Huxham on Air and Epidemic Diseases, vol. i. p. 139. 1788. 



( I'^G ) 



CHAPTER IX. 

OF THE SMALL-POX. 



fntroduction of the Small-Pox into Europe. Ravages com- 
mitted by it. Symptoms of the Disease. Distinct and 
Confluent Small-Pox. Malignant Small-Pox. Cohe- 
rent Small-Pox. Prognosis. Moi^hid Jippearances. Struc- 
ture of the Pock. Peculiarities of the Contagion of 
Small-Pox. Causes of Confluence. General Plan of 
Treatment. Practice of Inoculation. 

It is a commonly received opinion, that the small-pox first 
appeared in China and Hindostan, and that it was known in 
those countries from a very remote period. Such an opinion is 
certainly countenanced by a number of strong arguments and 
very curious considerations; by the mythology, the religious in- 
stitutions, the sacred and historical records, the medical works, 
and the uniform traditions of those countries. In the account of 
Southern India, however, by Colonel Wilks, an ingenious and 
plausible attempt has been made to overthrow this long establish- 
ed belief, to prove that the small-pox was first introduced into 
India in the sixth century, and to reconcile all the foregoing ar- 
guments ^with such a supposition. Without entering into the 
discussion of a question which has no practical bearing to re- 
commend it, it will be sufficient for my purpose to state, that 
inoculation was practised in India long before it became general 
in Europe*; and that we arc unquestionably indebted to Asiatic 
ingenuity for the first efficacious means of combating this formi- 
dal)le disorder. 

Whatever opinion may be entertained regarding the antiquity 
of small-pox in the East, no doubt exists as to the period when 
it first appeared in the West. This happened in Arabia, somc- 
wlierc about the an-a of the Hegyra, A. ,1). 622. From this 
point, as from a centre, the small-pox gradually spread into 

* CJoiisult Ml-. Moore's very vuluublc and interesting' woik, entitled " ///^V"- 
ry of tilt f^i/nuU-l'ojc." 



OF TIIK SMALL-VOX. 197 

Kurope and Asia Minor. It appears to have reached England 
towards the close of the ninth century.* All authors concur in 
representing the dreadful mortality occasioned by this pesti- 
lence wherever it appeared, and the consequent terror which it 
every where excited. Never was this more strikingly mani- 
fested than early in the sixteenth century, when some of the 
successors of Columbus carried the disease to America. The re- 
cord of the desolation that followed in its track, it is painful to 
contemplate. 

The general introduction of inoculation was brought about in 
1722, by the acute observation and spirited efforts of Lady Mary 
Wortley Montague. For a long time, however, the practice was 
viewed with great distrust, nor were its merits fully appreciated 
till towards the latter period of the last century. This change 
in the ideas of the world concerning the value of inoculation, 



* There seems to be good evidence of the existence of small-pox in FAiropc, 
and probably in England, long before tliis period. During the investigations 
made by Dr. Woodville, he discovered among the manuscripts in the IJritish 
Museum, as well as in the Cottonian collections written towards the end of the 
eighth century, the repeated occurrences of the word varwlse, and it is there 
expressly stated, that the inhabitants lived in constant dread of the small-pox. 
This account is corroborated by the notorious fact that in those collections 
there are preserved many prayers, exorcisms, and incantations intended to 
protect the people against variolous contagion. — We have high authority to 
show that the disease was known in other parts of Europe at a much earlier 
period. Marius Aventiccnsis, who was Bishop of Lausanne in the seventh cen- 
tury, though he does not "mention the year, uses these words. ^* Hoc anno 
VarioliB aim projiuvlo ventrisy Galliamy Italiamque valde afflixit." 

It is not generally known that for the successful and ameliorating influence 
of inocidation for the small-pox we are more indebted to one of the then colo- 
nies than to Great Britain herself. We feel a pleasure and a pride in bestow- 
ing the due meed of praise upon the state of Massachusetts. Lady Montague's 
elder daughter had been inoculated at Pera in April, 1717, by Maitland, sur- 
geon to the embassy, and by the same hand her infant daughter, aged three 
months, was inoculated in London in April, 1721. The elder was the first 
European inoculated for the small-pox, and the younger the first inoculated in 
Europe. — In April, 1721, inoculation for the small-pox was introduced into 
Britain by the Rev. C. Mather, aided by Dr. Boylston. This Rev. gentleman 
received the suggestion from some ephemeral account he had read of inocxila- 
tion in the cast. He was destined to pass the ordeal of all the ignorance, pre- 
judices and superstition of the times, not only of the populace but the faculty 
of physic, who were, with the exception of Dr. Boylston, enlisted against the 
project. A very protracted public controversy ensued, in which the clergy 
generally united against tlie physicians and finally so signally triumphed, tliat 
inoculation spread tlirough most of the then Colonies^ tJie practice was adopted 
without opposition long before the dissensions ceased in England. The suc- 
cess of the Rev. Mr. Mather and his able and spirited coadjut^or, Dr. Boylston, 
contributed very essentially to settle public opinion in Great Britain, and lo 
promote the progi-ess of inoculation in other parts of Europe. 

The Suttonian practice certainly was not original. 

The prop1)ylactic process of mercury first used by the two Taylors of Litcli 



field gave tlic first, and t)nly ycciu'iiy aguiust the effects of the variolous 



vjru'^ 



198 OF THE SMALL-POX. 

may be dated from the general adoption of the Suttonian prac» 
tice in 1766. 

For the first description of the small-pox we are indebted to 
Rhazes, one of the earliest of the Arabian authors, who flourish- 
ed in the tenth century. The increasing prevalence, and almost 
incredible malignity of the complaint, rendered it an object of 
investigation to almost all succeeding authors. Sydenham, in 
particular, studied the disease with an attention to minutiae, 
which can scarcely be paralleled in the history of medicine. In 
consequence, a mass of facts has been collected together con- 
cerning the small-pox, which does not admit of being detailed 
in the compass of an elementary work; nor, under present cir- 
cumstances, does it appear necessary to devote to it that degree 
of attention which it received in earlier times. I shall content 
myself, therefore, with an attempt to give a general notion of the 
effects of the variolous poison upon the animal economy. I shall 
then point out how far they admit of being moderated; and con- 
clude with a few remarks on the modification which small-pox 
undergoes from the mode of its reception into the system. 

Symptoms of the Disease, — The contagion of small-pox has 
a latent period of from ten to fourteen days, at the end of which 
lime it begins to show its deleterious effects upon the system. 
These vary both in kind and in degree; and attempts have been 
made to ascertain, if possible, the sources of the different forms 
which small-pox assumes. By some, the mildness or malignity 
of the disease have been attributed to differences in the conta- 
gion from which it emanated. Innumerable facts, however, are 
upon record disproving this notion, and showing that the seve- 
rest kind of small-pox may be taken from a case of the mildest 
sort. That other circumstances concur, I shall hereafter point 
out; but the student should remember, that the great principle 
is idiosyncracy, or peculiarity of habit. As there are certain 
constitutions that suffer more than others from lead, mercury, 
and the venereal poison, so arc certain systems unusually irrita- 
ble under the operation of the variolous virus. Many children 
suffer in this manner; and consequently an epileptic fit is, in 
early life, a frequent symptom of the accession of small-pox. It 
was very justly remarked, however, by Sydenham, that this 
does not necessarily denote, in them, a severe disease. The 
case is different when head symptoms accompany the attack of 
small-pox in more advanced life, and in robust habits. Early 
delirium, occurring under such circumstances, marks a deep im- 
plication of the Ijrain and nervous system, from which, in the 
progress of the disorder, much is to be dreaded. 

The contlilion of tlic body thut renders it so susccptihlc of the action of 
tlic vims IS ceHainly not pccidiar, but owin^'- to the ex(iuisite sensibiUty of the 
nerves to :dl poisons, For this reuson it bccomcf> necessary to reduce the 



OF THE SMALL-POX. 199 

power of life, and thus dimlnlKh this susceptibility, before wc can ensure a, 
milil disease. It cannot depend upon a peculiar irritability, because if we 
propose any given number of persons wc g-uarantee tlicm against the ciTiptioii 
in full form, and on the contrary there are very few who will not sullcr an 
aggravated disease, without some reduction of the general system. 

There seems to be a dift'erence between the convidsions of cliildren in the 
eruptive fever of small-pox, and epilepsy. The one is temporary, and never 
recurs unless in children hereditarily predisposed. The otlier will be again 
excited by many causes, and generally continues through life. r. 

Instead of .the epileptic paroxysm, sometimes children are attacked with 
cramps in the legs, gi-inding of the teeth, coma, convulsive twitchings of the 
jaw, a pain in the back, with an exacerbation of fever: the eruption is gene- 
rally copious, after coma and cramps of the legs.* 

Distinct and Confluent Small-pox. — The eruptive fever of 
small-pox lasts in general forty-eight hours, and is, in very many 
cases, not to be distinguished from an attack of inflammatory, or of 
common continued fever. The suddenness of the seizure is the 
best guide; but the severe pain of the back, the vomiting, and 
pain of the epigastrium on pressure, assist in the diagnosis.! The 
nature of the disease is put beyond a doubt by the eruj)tion, 
which is first observed about the forehead and wrists, and ex- 
tending gradually over the other parts of the body, is usually 
completed in twenty-four, or at farthest in thirty-six hours. On 
the appearance of eruption, the febrile symptoms abate, and in 
very mild cases are never renewed. In the severer kinds of 
small-pox, they only experience at this period a slight remission. 

The further progress of the disease depends so much on the 
quantity of the eruption, that nosologists have assumed this as a 
basis of distinction, and accordingly divide small-pox into two 
species; the distinct and the confluent. This arrangement, 
however, does not seem to me sufficient for practical purposes; 
and I therefore prefer a fourfold division, into the distinct^ the 
simple confluent, the malignant confluent, and the coherent. 
The peculiarities in each of these forms of the disease I shall now 
shortly advert to: premising that, in all, the disease divides itself 
into three stages; the first terminating by the appearance of the 
eruption; the second by the maturation of the pustules; and the 
third by the falling off of the scabs. 

1. The distinct small-pox shows itself in the form of elevated 



* Philip, p. 377, vol. i. 

f This does not distinguish it from several other diseases. Measles and scar- 
latina as well as bilious remitting fever all manifest a like sensibility to pres- 
siu-e of the same part. The only distinction between small-pox and these dis- 
eases previous to the appearance of the eruption is derived from the pcculiai 
fetor respired from the lungs, which cannot be defined by words, but which 
can never fail to be recognized by the olfactory nerves of any one who has 
smelt it. It bears some analogy to tliat of measles, but can be distinguished 
by those who have experienced both. p. 



^00 <^1' THE SMALL-1'OX. 

papula?. On the third day a small vesicle, having a central de- 
pression, may be observed on the summit of each pimple. It 
contains, at this period, a minute portion of a thin transparent 
lymph. An inflamed margin, or areola, now forms around it; 
which, when the vesicles are tolerably numerous, diffuses consi- 
derable inflammation over the neighboring skin, so as to give it 
a damask rose colour, and as the eruption advances, to occasion 
swelling of the face. About the sixth day the vesicles lose their 
central depression, and assume a spheroidal form. Suppuration 
has now taken place, and the pustules will be found to contain a 
thick matter of a yellowish colour. On the succeeding day, 
those which first appeared upon the face burst, and upon the 
eighth from the date of the eruption, scabbing commences over 
the body generally. The swelling of the face then subsides, and 
all fever is at an end. In about ten days more the crusts fall off; 
and the skin, though left for a time of a dark brown colour, is 
ultimately restored to its natural condition. 

Such is the usual course of the eruption of distinct small-pox, 
but it is subject to considerable variety. Upon the face it is 
sometimes more rapid, while upon the extremities it is com- 
monly more tardy, the pustules on the feet and legs being sel- 
dom fully ripened until the tenth or eleventh day from their first 
appearance. Their contents too vary in j)oint of consistence, 
and hence have arisen those distinctions of vesicular, vesiculo 
pustular, crystalline, horny, and water-pocks, which have been 
noticed by authors. 

The crystalline variety is more frequently attended with coma, delirium, 
and other s}Tiipt(>ms of typhus: at first the eruption looks as well as usual, of a 
good colour and distinct; about the third day they become irregadar in their 
shape; the lu-ine remains limpid throughout the disease, the matter is colour 
less, and i*arcly purulent: the pustules soon become pale on first coming- out, 
the interstices being flaccid, evincing the typhus character of the chscasc: the 
period at wliich the head swells is more uncertain than in the regular viu*iety; 
the swelling is often suddenly translated to the feet, when no salivation takes 
place;* if the fever is high, the eruption becomes confluent, and soon after 
mahgnant typhous symptoms appear: sometimes instead of tlie swelling, in- 
flammation tiikes place in the eyes, lips, throat, or brain, followed ])y abscesses.-} 
When the patient is debilitated tlie pustules do not appear, or if tlicy do, tliey 
do not ripen; the fever is not developed and the patient dies of coma in a few 
days: 

In tlie Ichorous variety of the disease, the fluid of the pock is transparent ii) 
consequence of imperfect su])puration, and when it dries, it exhiliits a liorny 
appearance: this is particularly the case among persons of a fair com])lc.\ion, 
:ind in projioilion to tlic darkness of the colour of the skin, the jnistidoa become 
brown, on drying: In the vesicular variety vesicles appear in the interval;; 
between the pocks. t 

2. When the papula: are very numerous, and exceedingly 

• I'luhp, p. o87, vol. 1 t l'JA'^» P- ^y«- ^ l*^^*^- 



OF THE SMALl.-POX. oqi 

close set upon all parts of tlic body, more especially on llie hcc^ 
we call the disease confluent. For the first day or two no dif- 
ferences are perceptible between this and the preceding species, 
except that the patient is more languid and oppressed; on the 
third, however, still more upon the fourth, the change becomes 
apparent. The vesicles on the face run together into one conti- 
nuous bleb, which, instead of a thick yellow pus, contains a thin 
brownish ichor. The face looks pale and doughy. On the 
trunk and extremities, the vesicles, although not actually con- 
fliient, are without areola, pale and flaccid. When the pus- 
tules break, extensive black or brown scabs are formed, attend- 
ed with intolerable foetor. At this period, the febrile symp- 
toms undergo a remarkable exarorbation, constituting what is 
called Secondary Fcx^er. But the mischief does not rest here. 
The violent action which has taken place in the skin, not having 
come to its natural crisis, is kept up. Ulceration of the cutis 
vera goes on beneath the scabs, and, if tho patient survives, occa- 
sions pits and scars. In other cases, boils, abscesses, tedious ul- 
cerations of the legs, and inflammation of the eyes, harass the 
patient, wear out his strength, and perhaps ultimately destroy 
him. 

Hitherto I have chiefly directed my attention to the effects of 
the variolous poison upon the skin; but it is further to be re- 
marked, that in some cases of distinct small-pox, and in almost 
all cases of the confluent variety, the mucous membrane of the 
mouth, larynx, and trachea is occupied by a peculiar eruption, 
which follows a regular course, and has a most material influence 
on the progress of the disorder. Though present in a greater or 
less degree in all severe cases, it is by no means in exact corres- 
pondence with the quantity of eruption on the skin. The ex- 
tent of vesicles upon the tongue, indeed, constitutes the only 
true index of the degree to which the trachea is affected. The 
symptoms to which it gives rise, are hoarseness, difficulty of 
swallowing, an increased secretion of saliva, cough, copious and 
viscid expectoration, and dyspnoea. In many cases of severe 
confluent small-pox, these symptoms are of the utmost impor- 
tance, and absorb the wliole attention of tlic patient. 

Sydenham tells us, that the spittinj^ sometimes begins as soon as the erup- 
tions appear, and sometimes not till a day or two after; it resembles the saliva- 
tion by mercuiy; towards the eleventh day it becomes viscous, is raised with 
difficulty, the patient is thirsty, coughs often while he drinks, discharging 
the liquor from the nostrils, the salivation stopping entirely, or recurring after 
a day or two; sometimes the swelling of the face abates, and recedes into the 
hands; which is sometimes favoured by the application of hot water, or 
poultices;* The dian-hoea in children does not appear so soon as the salivation 
in adidts, though when it does begin, it continues throughout the disease. 

* Rush, note to p. 77 of Sydenham. 
Vol it. — 2G 



202 OF THE SMALL-POX. 

3. Malignant Small-pox. — Such are the phenomena of sim- 
ple confluence. The student may imagine in how great a degree 
its dangers are aggravated, when to them are superadded the 
symptoms of malignancy and putrescency. Of these, one has 
been already mentioned, viz. early fierce delirium. The re- 
maining are, ha3morrhage from the stomach, bowels, or uterus, 
petechial vesicles, gangrene of the extremities, purulent ophthal- 
mia, diffuse cellular inflammation, and erysipelas. These cases 
sometimes prove fatal as eorly as the fifth, and seldom survive 
beyond the tenth day of the diteaso (the eighth of eruption). 

4. Coherent Small-pox. — It must be obvious, that in nature 
there can be no exact line of separation between the distinct and 
confluent kinds of small-pox. They run into each other by in- 
sensible decrees. Now to those cpses which are intermediate be- 
tween the perfectly distinct and confljent, we give the name of 
coherent, or semi- confluent. This term applies, first, to cases 
where the eruption is uniform, but where the papulae are not 
sufficiently numerous to coalesce before the fifth or sixth day; 
and, secondly, to those where the eruption is i7i patches, con- 
fluent in one part, and distinct in another. 

The appearances on dissection in those who die of small-pox 
are confined, as far as my observation extends, to the mucous 
membrane of the trachea and the pluera. I have never been 
able to trace any morbid appearances in the head, even where 
cerebral affection was most decisively marked during life; and 
the abdominal viscera appear to be singularly exempt, under all 
circumstances, from the influence of the variolous virus. No 
vestiges of pustules have been ever traced at the Small-pox Hos- 
pital in the cavity of the abdomen. 

When small-pox proves fatal about the tenth day, it is com- 
mon to find evidences of active inflammation in the larynx and 
trachea. A copious, dark-coloured, and viscid secretion (quite 
peculiar to this complaint) lines their inner membrane, which is 
highly vascular. At a later period of the disease, one cavity of 
the thorax is occasionally found loaded with purulent effusion, 
the pleura having become implicated in the course of the disease. 
The substance of the lungs is then consolidated by the pressure 
of the effused fluid. Variolous pleurisy (as it may be called) is 
rare, and by no means well marked in any of its stages. 

Prognosis. — The prognosis in small-pox is regulated almost 
entirely by the form which the disease assumes; but of course 
the strength of the patient's constitution is, to a certain extent, 
to be taken into account. Distinct small-pox is a disease of lit- 
tle or no danger; while the confluent variety is attended, even 
under circumstances comparatively favourable, with imminent 
hazard to life* When malignancy and confluence are nssocia- 



• The ckng-cr of tho itisoasc i^ known l>y Its state upon tho Tmcc'; if 



Ol- lllE b MALL r OX. 2{)3 

ted, the case is utterly hopeless. The mortality in small-pox 
simply confluent is about three in five. Coherent cases prove 
fatal in the proportion of about one in four. Upon the whole, 
it is computed, that of every six persons who receive small-pox 
in the natural way, one dies. The most unfavourable symptoms 
are those which indicate affection of the brain, larynx, and bron- 
chia, violence of fever, and strong determination of blood to the 
skin. The most favourable are, quiet of mind, a tongue free 
from vesicles, swelling of the face, but above all a small, soft, 
and yielding pulse. From the tenth to the thirteenth day is the 
period of the greatest danger; but to feeble constitutions, and es- 
pecially to scrofulous children, the sequelae of the disease are 
scarcely less formidable than the violence of its crisis. 

Before proceeding to the method of treatment in small-pox, 1 
may notice a few circumstances connected with the disease, 
which are either objects of pathological curiosity, or of interest, 
as suggesting the means of lessening its violence. 



fluent on the forehead, and more particularly at the roots of the hair or on the 
face, and if the pox run into each other so as to make it appear as if it were co- 
vered with parchment, the dang-er is considerable, whatever maybe its appear- 
ance on other parts : sometimes the matter of the pustules oozes out and leaves 
tlie vesicles empty (siliquosa;) if, then, on the patient's walking out, on the use 
of the cold ba^ or tonics, they fill with a proper matter, it is always a good 
sign :* the later the eruption the more favourable is the case ; as is also the da- 
mask colour of the skin between tlie pustules: the swelling of the face in mild 
cases, when slight, is favourable; when in excess, the contrary: If the stools 
are unusually foetid in the confluent kind, it is a bad omen; the higher colour- 
ed the matter is, the more favourable is it in this variety; when it is black 
orsanious, it is extremely dangerous. f 

Sydenham says, that if the patient sweats freely, in the beginning of the 
disease, and if he promote it by cordials and hot regimen, and the face in conse- 
quence towards the eighth day becomes flaccid, wliite or pale between the 
pocks, whilst they look red and continue elevated, the sweat at the same time 
ceasing, without the possibility of raising it again by any means, then delirium, 
frequent voiding of ui-ine in siniiU quuu titles, great restlessness and sickness, at- 
tend upon these symptoms, and usher in the deatli of the patient. In cold 
weather, in old persons, or if bleeding has been used, then a hot and cordial 
regimen does not so certainly hinder the sweUing of the face, and is not so 
fatal as where the eruptions are many, or when the disease happens in the 
spring, the patient is in the prime of hfe, and no blood has been taken away: 

If the spitting in the confluent kind, which generally ceases about the 
eleventh day, is not assisted in its good effects by the continuance of the swell- 
ing of tlie face, and of tlie hands, which last begins about tliis time, death ge- 
nerally follows. From the effect of the hot regimen when the system is in- 
flammatory, debility is produced to so great a degree that the swelling of the 
liands vanishes with the sahvation, when it should continue increasing for a 
day or two (a most favourable sign,) as the sahvation disappears. When the 
saliva, from being thin and ichorous, and easily expectorated, becomes tliick 
and viscid, falls down into the wind-pipe, threatens suffocation, and is thrown 
up into the nostrils, it is unfavourable; the patient shortly after is often seized 
with a hoarseness, stupor, drowsiness, and sooii dies. 

* Phihp, pp. 373. 380, vol. i. f Ibid. 



204 <^>I' 'J'li'^ SMALL-rOX. 

Structure of the pock. — The seat and structure of ihe pock 
has been a frequent subject of inquiry, and by some is supposed 
to be still involved in obscurity. The rate mocosum appears to 
be the true seat of the small-pox pustule, but the inflammation 
sometimes dips down into the cutis vera. The pock, when mi- 
nutely examined, exhibits in its early stages a cellular structure, 
the walls of which are perfectly transparent, and appear to se- 
crete the fluid which distends them. At the bottom of each pock, 
a small slough of the cutis may be observed from the fifth to the 
eighth da)', of a circular form, and about the thickness of writing 
paper. By several eminent pathologists, this slough is consi- 
dered the certain test of small-pox, and to be owing, not so much 
to the intensity, as to the peculiar kind of the inflammation. 

Peculiarities of the contagion of Small-pox. — The disposi- 
tion to receive small-pox is so general throughout the hu- 
man race, that few persons are met with who resist it during 
their whole lives, when fully exposed to its influence. All ages 
are alike susceptible of it. It is communicable by the mother to 
the foetus in utcro, but under such circumstances it has almost 
invariably proved fatal to the child. There is even reason to 
believe that a mother who has already passed through the disease 
may communicate it to the fostus. 

Unborn children do not always take the small-pox from then* mothers la- 
bouring' under this disease; and mothers have passed through tlie disease by 
inoculation, and children of whom they were pregnant at the same time have 
afterwards been inocidated and have taken the disease.* In some cases, how- 
ever, children are born with pustules upon them, which they must liave taken 
from the mother, who had the disease; but in other instiinces, the cliild has 
been born with the eruption of t!ie small-pox upon it, thoug-h there w;xs no 
appearance of the disease in the mother. It is the opinion of Underwood tliat 
very young children, from a month old to a year, contrary to what the autlior 
has stated, are not so susceptible of it. 

With reg-ard to the distance at wliich it is communicable. Dr. 0*Uyan of 
Lyons, has proved by putting dossils of lint and silk strongly impregnated with 
variolous matter in the ccnLrc of an uval table, the least diameter of which was 
three feet, and by exposing children to it every morning" and evening' for a 
week, sometimes in the open air and sometimes in a room, that they rem:uned 
free from the disease, lie also proved that children who took the small-pox 
afterwards by inoculation, were not susceptible of it tliough placed within two 
feet of a child for the space of one hour daily for a fortnight ;-[- patients in ge- 
neral, therefore, must approach nearer, in order to receive the disease. Much 
must depend upon the purity of the air, the mass of contagious matter, as well 
as the susceptibility of the system. C. 

The deleterious effects of the small-pox virus upon the gravid 
uterus are very remarkable. It seldom fails to occasion abortion, 
especially in the early months of pregnancy. In general, oneat- 

• Good, vol. ii. p. 416, quoting Sir Geo. Baker. See cases in the Mcdico- 
Chirurgiral Trans. London, Vol. i. p. 271, by Jennerj also Quier'ft account 
of small-pox at Jamaica, p. 103. 

t Batcman's succinct account, p. 147. Lond. 1818. 



OF THE SMALL-POX. 205 

lack of the small-pox secures the system from the dise€«e for 
ever after. Yet some exceptions to this law have been met with. 
Unequivocal cases of wliat is called secondary emall-pox are 
recorded in the writings of authors, as having occurred in all 
ages and countries; and the second attack, though generally mild, 
and modified, has proved in some instances severer than the 
primary. Even fatal cases of secondary small-pox have been re- 
corded by authors of undoubted veracity. 

Causes of Confluence. — I have already remarked, that the 
comparative mildness or violence of the disease depends princi- 
pally upon some peculiar susceptibility of the system to the va- 
riolous poison; but some other circumstances concur. Delicacy 
in the structure of the skin is probably concerned in the pheno- 
menon; for in this way only can we account for the greater-dis- 
position to confluence upon the face than on other parts. The 
rete mucosum is there loaded with vessels, which have mani- 
festly a greater disposition than common to receive red blood. 
Further, whatever encourages the blood to tlie surface of the bo- 
dy has a tendency to produce confluence. Hence it is that a 
long succession of close and moist weather, exposure to great 
heat (as in the trade of the sugar baker), the free use of ardent 
spirits, diaphoretic medicines, the warm bath, and stimuli ap- 
plied to the skin, aggravate the disease in a high degree; while 
cold and frost, and light clothing, and tlie antiphlogistic regi- 
men, tend greatly to lessen its severity. 

Treatment. — The general principles of treatment in small- 
pox were for a long time misunderstood, and measures were con- 
sequently adopted which greatly increased the mortality of the 
disease. In the distinct small-pox very little is requisite; and 
the danger in confluent cases is urgent under any system of ma- 
nagement; yet the advantages of a well-regulated treatment are 
as obvious in small-pox as in any other disease. 

During the eruptive stage the object is to moderate inflamma- 
tory excitement generally, and to lessen the quantity of eruption. 
For this purpose the patient is to be freely exposed to a cool at- 
mosphere, and the strictest antiphlogistic regimen is to be pur- 
sued. Great diversities of opinion have prevailed regarding 
the propriety of blood-letting in this and the other stages of 
small-pox. There is no reason to believe that it lessens the 
number of pustules; and it has been supposed to impair that 
strength of the body which is indispensable throughout the lat- 
ter stages of the disease, when extreme weakness so often exists 
with extensive ulceration and gangrene. In forming a judg- 
ment however on this point, it is necessary to bear in mind, that 
these symptoms, though they sometimes arise from real debility 
of the powers of life, yet are often attributable to excessive in- 
flammation of the skin, which might have been prevented by a 



206 OF THE SMALL-POX. 

judicious employment of the lancet. It is to be remembered al- 
so, that in small-pox, fully as much as in any other form of fever, 
there is a tendency to congestions and inflammations in the head 
and thorax. These must be treated upon the same principles as 
have been already urged with regard to fever generally. 

We cannot here too much insist upon the idea, that small-pox, like other fe- 
vers, is typhous, typhoid, and inflammatory in its type. When it attacks a per- 
son of a high phlog-istic temperament and robust constitution, all the means be- 
fore recommended are necessary : when typhoxis, those advised under that head. 
Huxham describes it as occurring" with a low, weak, and fluttering pulse, gid- 
diness, heaviness, nausea, and puking, weakness and weariness from the be- 
ginning, as in typhus, and these symptoms continuing for seven or eight days 
before the eruption appeared? petechise, haemorrhagies, black pustules also 
attend it, and, as he states, the hot and cold regimen, bleeding and stimulants 
are proper according to the nature of the disease » this rule applies also to tlie 
preparation: in a typhous epidemic small-pox, the system should be supported 
and not depleted. 

Attention should be paid therefore to the concomitant symp- 
toms, and the character of the pulse; and where there is evi- 
dence of local determination, it must be obviated, according to 
its urgency, by local or general bleeding, at any period of the 
disease, without reference to the affection of the skin. Occa- 
sional purging and the usual antiphlogistic treatment are advisa- 
ble during the whole period of febrile excitement. 

I. The signs by which bleeding is shown to be expedient, arc when deli- 
rium is present, and in the distinct kind, when the eruptions are numerous and 
the face does not swell, and when by improper stimulants the system has been 
too much excited; and exposure to the air, bleeding, and cold drinks have 
then a fine effect: 

Bleeding and occasional purging are also necessary, after the patient has 
begun to go about and returned to his usual regimen, to prevent local inflam- 
mations; as biles, chronic inflammations of the eyes, lungs, &.C., and swclhng 
of the legs; fomentations are also useful in this last symptom.* 

An emetic given at the time of the appearance of the snudl-pox, particularly 
when they tlu-eaten to be confluent, has a most excellent effect; also, when 
from a typhous state of the system, they remain long buried in the skin with- 
out appearing, it is very useful; particularly if assisted by enemataand gentle 
cathartics, it produces foetid discharges which keep up the typhous st:ite. 

II. A salivation is said l)y Sir Geo. Baker to render tlie small-pox milder in 
tliose who tiike the disease when in this state :f Calomel is also said to have 
the same favourable effect when given as a purgative. 

III. The patient should drink freely of acid and cold drinks; use the cold affu- 
sion, when the skin is liot and dry; expose himself to the air as much as possi- 
l)le, and if there are convulsions, hmdunum may be given to abate tlicm;*four 
drops to a child of a yeiu- old, eight drops to one of two, he. If the fits arc 
moderate, cool air only is necessary. Tlie use of the cold affusion lessens tlic 
fever and the mmiber of the cni])tions, and lluis prevents the disease from be- 
ing confluent: The air of the room should be completely cool, avoiding, how- 
ever, a reduction of temperature, sufiicient to produce chilliness: The patient 



Sydenham, Hush's, p. 91-95. j buns on Bpidgmics, p. 42. 1772. 



OF THE SMALL-POX. 207 

should lie on a matrass, to attain this end more completely; the room should 
be larg-c and airy; the bed linen must often be changed: We must, however, 
tiike care that the depletion be moderate, and cautious, otherwise the patient 
may fall into typhus; the same remark applies to the use of purgatives. 

Dr. Rush tells us, that the Indians plunge tliemselves into cold water as soon 
as they perceive the eruption of the small-pox: It is pi-actised by Europeans in 
hot countries, and with success where the pustules have a flaccid appearance.* 

In the confluent variety, however, h is necessary to be very cautious how 
cold air is applied, as syncope and convulsions sometimes follow it: these occur 
about the period of maturation most generally; and more particularly if the 
patient has been debilitated by the hot regimen or other improper treatment; 
Any debilitating cause, however, will produce the same effect: la the crystal- 
line vai-iety, which tends r:>pidly to typhus, it is not useful .f 

Local bleeding is viduable, where there is coma or inflammation of the eyes; 
also where there is gi-cat pain in the head, with throboing of the temples and 
other s> mptoms of phrenitis. t The same remark applies to any other lociJ 
inflammation. 

IV. Purgatives are useful in proportion to the severity of the disease; if, 
owing to weakness, in cases where there is no evacuation but that from the 
salivary glands, their suspension becomes necessary, the patient, according to 
Professor Walker, must be considered as desperate: However, even the cases 
in which tlie gangrenous blisters occur, considered as mortal by Sydenham, 
have been cured by the use of these remedies: in general, though the symp- 
toms of typhus have come on, they are indispensable, regulating their use by 
the state of the strength; if tlie patient sinks, of coui-se they are to be discon- 
tinued. 

V. During the exacerbation, the use of antimonials with nitre will alleviate 
the symptoms; also saline and effervescing draughts, cream of tartar water,, 
and lemonade: To allay the inflammation of the throat, gargles will be proper, 
as also the inhalation of the vapour of warm water or vinegar. 

VI. The following facts show the value of this depletory practice, and the 
danger of the contrary: the use of stimulants early in the disease, before the 
cniption or the typhous symptoms have appeared in robust and young people,, 
where there is great fever, converts a case, which would otlierwise have been 
distinct, into the confluent kind, and the pustides, instead of coming out clear- 
ly, are concealed in the skin and do not rise above it.§ Early confinement, in 
the opinion of Sydenham, produces, from the heat of the bed, bloody urine, 
purple spots, and other moi-tal symptoms, particularly in young persons, and 
in tlie first stage of the disease. 

When the vesicles do not rise, or are filled only with a bloody- 
serum, and when the pulse is weak, the skin purple, marking a 
failure of the vis vita, the tone of the system is to be supported 
by wine, brandy, bark, camphor, and aromatics, with the occa- 
sional exhibition of laxatives. 



I. The symptoms of debility may super\-ene, either on the emptive or on the 
secondary fever: When the eruption is distinct, it never is followed by this 
fever in any considerable degi'ee,|| liark in cases in which debility appears, is 
One of the best tonics; under its use, the pustules fill with good matter, and the 
petcchi?e disajipcar. Sometimes, great dejection of spirits and fear even in 
the rolnist produce typhous symptoms; then if great, stimulants, as wine whey, 
volatile alkali become necessary: Sometimes bleeding from the arm raises the 
pulse in a depressed state from this cause in robust jieoplc : Judgment only 
can decide from the circiuTistanccs, when this case occurs. 

* Philip, p. 40vS, vol. i. I Ibid. p. 409. i Ibid. p. 406. § Sydenham. 
i! Philip. -IIV vol. i. 



206 OF THE SMALT,-POX. 

When the pustules are bloody, alum mixed with bark, has a good effect; the 
sulphuric acid has also been used with advantage: Dr. Wright recommends a 
mixture of a vegetable acid >vith common salt in tlie low typhous stage.* 
Huxham recommends nutritive diet, wine, &c., the mineral acids, with bark, in 
the confluent kind with petechia, when the pox are small and black, and the 
matter fetid and sanious; in the ichorous .variety in which the matter is watery, 
neither the vegetable nor the mineral acids do any good. In this last kind, 
the matter forms large vesications filled with water, wliich at lengtli break 
and discharge, and leave almost the whole surface excoriated; an atrophy 
succeeds from the great discharge, or the matter is absorbed, when the pustules 
do not break, and epilepsy, delirium and syncope are the results: A natural 
diarrhoea in this case is favorable, as also copious sweats and lateritious urine : 
Camphor, opium, wine whey, volatile alkali are useful in bringing out the pus- 
tules in this variety : coffee also drunk through the whole course of the dis- 
ease has a good effect:-}- Blisters are also useful, and opening the bladders 
with a lancet: Sometimes, a proper union of diuretics, as, nitre, spiritus nitri 
dulcis, with stimulants, has a fine effect: The sick should be raised to their 
knees frequently, as it induces them to make water, when if they are left to lie 
upon their backs they will not think of it.t 

II. Dyspnoea, sneezing, and cough, from the larj'nx, trachea, &c. being co- 
vered by pustvdes, or from a swelling of the fauces, are relieved by large blis- 
ters, applied externally to the throat and back of the neck. If they arise from 
viscidity of saliva, a gargle of oxymel of squills and water and the apphcation 
of sinapisms to the hands and feet, witli gentle laxatives, arc proper; syringing 
the fauces is also useful. Cyder and honey; vinegar and honey; honey and 
water; oxymel scilliticum,with borax or nitre; will make excellent preparations 
for tliis purpose. Sometimes the mucus becomes tenacious from not drinking 
freely during the illness, which should be regarded as of primaiy importance :§ 
The diet should be entirely liquid: In the black confluent small-pox, solids 
cannot be swallowed; wine whey, wine and water, barley water with wine, &c., 
should tlien form the drinks. 

If the difficulty of breathing be great, give the tartarized antimony, H or accord- 
ing to Brocklesby, small doses of the ipecacuanha: Full vomiting also alleviates 
tJiis symptom, as also the stupor and suffocation, which depend upon tlie vis- 
cidity of the sahva, and which are removed with it. The sudden suppression 
of the salivation is often produced by the supravention of pneumonia. 

Where, on the other hand, the salivation is so copious, that suffocation is 
threatened by the falling of the mucus into the trachea during coma, catliartics 
are praised by Vogel as the most successful plan. 

When the skin is completely covered with one general scab and the salivation 
ceases, it must be renewed if possible, and a free diuresis is also to be promo- 
ted: Both often fail suddenly: Blisters to the ancles; laxative clysters; ex- 
pectorants, as squills, lac ammoniac should then be used. 

HI. In the confluent kind,thc diarrhcca, which is often troublesome, particu- 
larly in children, should not be stopped; if very excessive, it may be moderated 
by either kino, extract of logwood, catechu, or alum, given in the dose of ten 
grains in a little cinnamon water, every three or four hours: This, however, 
must be done cautiously, and if it produce any l)ad effect, the looseness must 
be reproduced by laxatives, t 

Sydenham tells us, that a looseness and sinking of the pustules, in the dis- 
tinct kind, are dangerous symptoms and arc often brouglit on l)y cold, or too 
considerable evacuations: In the confluent kind, these symptoms, particularly 
diarrluta in children, do not indicate danger: on tlic contrary, they are part 
of tlie disease; Stimulants arc then valuable: Pain in the heart and sickness of 
the stomach, also, shew their necessity. 

• Huxham, vol.i. p. 148. I.ond. 1788. f Ibid. 150. t Hnxhani. § Huxliani, 
|). 161 . 1 JMiiUp, p. 41.'?. vol. i. 1 Ibid. p. 414. vol. i. 



OF THE SMALL-roX. 209 

IV. When excessive perspiration threatens debility, the patient should be 
exposed to the cool air, and be out of bed as much as possible.* Vomiting- may 
be reUevcd by diluents, as toast and water, chicken water, twenty grains of salt 
of tartar taken with a table spoonful of vinegtir, or a tea spoonful of lemon 
juice, with four or five drops of laudanum in each dose; mint water, cinnamon 
water, spirits of turpentine, tenor twenty drops every hour, are also useful: If 
the matter ejected be acid, alkalies will be proper absorbents; as, chalk, and 
magnesia: bitters; as, quassia; the extract of cascarilla will often have a very 
fine effect: A blister to the pit of the stomach, also succeeds.f If heat, head- 
ache, sickness and load at the stomach, with great restlessness or stupor come 
on about tlie sixth or eig-hth day from the eruption, the body being costive, or 
attended with tenesmus, glysters are necessary: 

V. StrangTiry, often, is troublesome in persons who are vig-orous and accus- 
tomed to make a free use of spirituous liquours; neg-lect of evacuations, early 
in the disease, also, produces it: Salt of amber is recommended by Dr. Came- 
ron; it would appear to suit best the low states of disease, when the skin is 
cold and the arteries debilitated: When the pulse is high and the skin hot, ex- 
posure to the cold air, dashing water on the legs, walking about the floor in a 
loose dress will have a good effect; care, however, must be taken to avoid the 
use of this remedy when the system is in danger of faUing below par: If there 
is merely difficulty of making water, small doses of camphor and opium given 
at short intervals will relieve it. ^ 

VI. When epileptic fits are frequent and threaten death, the warm bath and 
opium administered, either by the mouth or |by injection, generally succeed; 
They produce perspiration and prevent the return of the fit; Dover's powder 
has the same effect: Cataplasms applied to the feet do good: Laxatives are 
also necessary.§ 

VII. The application of some warm milk or mild ointment is necessary to 
keep the eyelids from adhering together; and if the eyes are inflamed, an 
eye water, composed of 10 grs. of the acetate of lead to 6 oz. of water; or of 
3ii of alum to 3 oz. of water, will alleviate the inflammation, and prevent the 
pustules from appearing on the cornea. 

VIII. The application of lead water will prevent the appearance of the pus- 
tules, and if they are numerous on the face, sinapisms to the ancles, with im- 
mersion of the feet in warm water, will be proper to lessen the deteraiination 
to the head. II 

IX. Sudden cold applied to the surface often produces, particularly about the 
period of maturation, a subsidence of the swelling of the hands and feet, and 
a retrocession of the eruption, especially if the patient be much debilitated; 
the same effect is, also, caused by the excessive use of a hot regimen; by too 
much exertion, as in sitting up; by syncope; by strong emotions, as, teri'or, 
grief, by profuse evacuations; in fine, by any cause which debihtates excessive- 
ly: Wine, opium, and bark succeed best in relieving these symptoms, more par- 
ticularly when they are produced by excessive evacuations : When they proceed 
from cold, the wann bath, sinapisms and blisters are proper: When they are 
the result of a hot regimen, cool air, cold diluents and bleeding are the reme- 
dies. 'Ammonia, blisters to the feet, and the semicupium are recommended by 
Vogel.t Blisters to the wrists will be found to be very valuable on the retro- 
cession of the swelling of the face, provided that of the hands does not recede 
at tlie same time: Dr. Cameron recommends wrapping the anns and legs in the 
citrine ointment, which stimulates the pustules to the secretion of pus, as far as 
the ointment extends, andreheves the patient immediately from this most dan- 
gerous state: Anointing the whole body with mercurial ointment is sometimes 
useful; some ointment, as, the citrine, however, is better, as it produces an 
immediate change in the state of the skin : The necessity of these measures 

*Philip,vol. i. p. 415. f Ibid. p. 414. ^ Ibid. p. 416. § Ibid. 417. I| Ibid. 
^ Ibid. p. 418-19. 

Vol. II — 27 



210 OF THE SMALL-POX. 

may be inferred from thedebilitated state of the patient, as the recession of the 
eruption is generally a consequence of it: 

X. Tissot recommends the warm bath to the feet when the swelling of the 
face is excessive.* 

XI. Sometimes the eruption is delayed beyond the time of its proper appear- 
rance; then venesection, employed, however, withtlie utmost caution, a dose of 
laudanum, and the tepid bath promote its reappearance: 

XII. When the pustules appear in the nares and obstruct them, injections 
are recommended to separate them: when they are longer drying than usual, 
opening them is very useful^ and if the scabs adhere too long, fomentations 
are tlie best means to produce their separation: In case of hemorrhagies, the 
serum aluminosum is recommended to stop them; it is to be appUed to the 
parts from which they proceed, as the mouth, nose, &c. "With regard to the 
various modes of preventing pitting by applying mild ointments to the surface, 
it is doubtful whether they have any effect; and as cliildren are born pitted 
with the small-pox, it is certain that the contact of air is not the cause.f 

XIII. Sometimes the matter produces fever and death by being confined 
beneath the cuticle of the soles of the feet of working people. This happen- 
ed to Quier in Jamaica: It is attended witli severe fever, restlessness, and deli- 
rium, with violent pains on touching their feet: The cuticle was removed, and 
poultices applied to the sole, wliich removed all uneasiness, c. 

When the pustules are nearly maturated, and throughout the 
latter stages of the disease generally, great benefit is experienced 
from opiates, in relieving the irritation of the skin and procur- 
ing sleep. 

I. In the confluent variety it is necessary to prevent the recession of the 
pustules; by keeping up the saUvation, by small doses of laudanum, small beer, 
wine whey, Etc.; in children opiates are hurtful, when they stop the diarrhcea, 
which is a substitute for the sahvation in adults; these medicines, to persons 
above fourteen, are useful, t by promoting sleep, and keeping up the saliva- 
tion and the swelling of the hands and feet: Sydenham directs about fourteen 
drops of laudanum to be given every night after tlie eruption is over, to the 
end of the disease. It has a better effect if given earher in the evening to pre- 
vent the fever. 

II. Sydenham further tells us, that opiates are indicated in other instances: 
When, in the distinct smull-pox, by a hot regimen and continual sweats, tlie 
face docs not swell on the eighth day, but is flaccid and the spaces between 
the eruption are pale, a dose of laudaimm has tlie happiest effect. 

III. When a hot and stimulating regimen has produced delirium, great sick- 
ness, suppression of urine, free exposure to the open air, copious venesection, 
or the administration of opiates is the only plan: The return of tlie swelhng of 
the face is the first evidence of their useful effects: 

Venesection is also useful when tlie pulse is full and strong, and the symp- 
toms inflammatory at the time of the ap])earance of the sccondiuy fever: The 
blood is often as much cupped and buffy as in pleurisy: If, on the contrary, 
the pulse flags, the skin is shrivelled and pale, sunk or livid, the limbs cold, 
then stimulants are absolutely necessary :§ lilistcrs to the ancles and wrists; 
warm and strong wine whey, volatile alkali, &.c. c. 

There is a remarkable resemblance in the symptoms of the 
latter stages of small-pox to those of extensive burns and scalds, 



Philip, vol. i. p. 420. t Ibid. 421-422. vol. I. \ Sydenham. 
^ Huxham, p. 158. London ITHS. 



OV THE SMALLPOX. 211 

where the good effects of opium are well ascertained. While 
the scabs are separating, a cordial plan of treatment is often ne- 
cessary, but it is requisite also in many cases, to look to, and 
counteract by laxatives and a proper diet, the tendency to local 
inflammation, which may continue even to the very latest period 
of the disease. 

Considerable difficulty has always been experienced in the 
management of the many severe sequelae of confluent and cohe- 
rent small-pox; but to meet these cases no express rules can be 
laid down. When the constitution is much enfeebled, and scro- 
fula brought into action, tonics are of some service; and I have 
derived considerable benefit from the decoction of sarsaparilla. 
A generous diet, with an allowance of wine or porter, should be 
permitted; but change of air is the measure of most decided efli- 
cacy. The disposition to boils cannot, I believe, be counteract- 
ed by any medicinal treatment. 



INOCULATION. 

When the matter of small-pox is inserted under the skin, a 
pimple appears on the third day, followed by swelling in the 
axilla. The pimple then becomes surrounded by a jagged areola, 
in which small vesications are observable. On the seventh oral 
farthest the eighth day from the insertion of the virus, rigors 
occur, and in forty-eight hours afterwards the eruption appears.* 
In a large majority of cases, the eruption proves to be of the 
?nild and distinct sort; and in very many instances the number 
of pustules over the whole body does not exceed one hundred. 
The further progress of the disorder difiers in no respect from 
that of the distinct casual small-pox as already described. 

The manner of performing the operation of inoculation is by the insertion 
of a little of the matter made nearly fluid under the skin, with the point of a 
lancet, or a needle, making- a wound which will draw a single drop of blood, 
and suflTering it to dry completely : A slight itching with a minute pimple ap- 
pears in three or four days; a swelhng takes place in the axilla, with pain and 
weight; on the seventh or eight day shiverings, head-ache, witli fever take 
place, and the eruption appears: "When the case is unfavourable, the inflam- 
mation is of a purple colour round the pustule : When otherwise the circle 
around it is of a deep red and narrow.-}- If the inflammation does not take 
place by the fifth day, the inoculation may be repeated. 

Taken internally with a dose of medicine the variolous matter produces no 
effect: Rubbed on the skin without wounding the surface, it also does not 
communicate it.t After inoculation the wound inflames and suppurates, and 



* To this it is owing that the inoculated takes precedence of the natural 
disease, 
t Good's Study, vol. ii. p. 424. ^ Thomas, p. 250. 



212 OP THE SMALL-POX. 

though the constitution does not sympathise, nor the disease take place, yet the 
matter taken from the pock will reproduce the disease in another pei-son. c. 

Nothing has ever been suggested calculated to throw the small- 
est light on the curious fact, that the mode of reception into the 
system should thus influence the quantity of eruption. To so 
great a degree does this take place, that the mortality by inocu- 
lated small-pox, without any restriction as to age or strength of 
constitution, does not exceed one in five hundred. 

Indeed so much is this the case, that it is now beheved that preparation has 
but httle effect upon the disease, produced by inoculation; though M. Des- 
serts adduces a number of facts to prove that the natural small-pox is rendered 
much milder by the use of mercurial medicines, and Van Woensel thinks he 
has proved the same thing in regard to the effects of calomel given some days 
before inocidation, and till the eruptive fever commences. 

There can be no question that as the type of small-pox is influenced by tlie 
fullness and plethora of the habit, that this disease must be milder in the inocu- 
lated, because they are prepared by a low regimen: But there is another rea- 
son; inoculation produces the chsease from a ^mall poi-tion of matter inserted 
into the skin; taken in the natural way the system receives a greater quantity of 
the poison, and of course the disease must be more violent: The system may 
be inhaling the poison for many days before it breaks out, and thus it may ac- 
cumulate and at length appear in its most violent form; in inoculation also 
persons but slightly disposed to it are forced into the disease by the inocula- 
tion, it must therefore be milder, whereas those who take it in the natural 
way are generally those who have the strongest predisposition, as they are 
left to the causes naturally and generally acting at the time : this view of inocu- 
lation places the small-pox on a footing with other fevers, c. 

We select for the period of inoculation that season of the year, 
and that time of life, when inflammatory tendencies are least to 
be expected. It ^is sufficiently ascertained that be^^ond a few 
doses of a cooling aperient, no preparatory course of medicine 
is requisite. A spare vegetable diet, cool air, and subacid drinks, 
will contribute to render the disease mild and safe. Improper 
management may of course increase the quantity of eruption, 
and with it the danger of the patient. Some attention, there- 
fore, ought always to be paid to the treatment of inoculated 
small-pox; but the principles already laid down arc equally ap- 
plicable in the present case, and will be sufficient without fur- 
ther detail for the guidance of the student. 

To induce success from inoculation, a good habit is necessary: The season 
should be cool; the patient should be kept in an airy and well ventilated place, 
at the same time be always comfortable: The matter should also be taken 
from a healthy person, and it should be fresh. 

If the epidemic constitution is typhous or inflammatory, we must reguUte 
our proceeding accordingly; thus it would not be proper to observe a low re- 
gimen during the prevalence of intermittents or of the typhus syncopalis; on 
the contrary, it would certainly bring on either of these diseases and be at- 
tended with death. Huxham gives many instances where, during tlie preva- 
lence of low typhous diseases, the small-pox took the s;imc character; this was 
so in the years 1740, 1741, and 1745: He states also that the use of mercurial 



OF THE SMALL-POX. 213 

purges before inoculation, frequently brings on petechlse, hemorrhages, and 
other t\'phous symptoms.* He dwells with great emphasis on the different 
types of small-pox: It is attended with no fever at all, or is typhous or inflam- 
matory in everf^ degree: He saw it with a low typhus for eight days before the 
eruption. 

In general, in an ordinary state of the air and disease, it Is ascertained that 
inoculation had better be performed on the sti-ong and healthy; not on preg- 
nant women, on the debiUtated from any cause, nor on very young infants, on 
those who have scurvy, nor on those who are labouring under an acute disease: 
Children should not generally be inoculated till after they have cut their first • 
teeth. In infants the pustules are almost always more numerous; and, there- 
fore, in them it is dangerous in proportion to their youth; they should at least 
be four months old: Underwood states that, even at a later age, they are apt 
to die if inoculated. Old people pass through it safely if they are not too weak. 

Some mild mercurial purgative every tliree or four days should be given for 
three times, if the patient is plethoric; if not, once or twice previous to inocu- 
lation; and when the patient is dehcate, no preparation whatever is necessary: 
for an infant, one grain or a grain and a half of calomel should be taken at 
night, and a teaspoonful of castor-oil next morning repeated as above directed: 
During this preparation the diet of the mother should be entirely vegetable; 
adults may take a full dose of salts, castor-oil, or calomel and jalap, with the 
above diet: The character of the disease depends entirely upon the state of the 
system; if extremely febrile, it becomes confluent; if debilitated, the pox do 
not fill and the patient dies in a typhous state: The matter may be taken, 
either from a mild or a confluent case, from the varioloid form, or from the 
imperfect pock, produced by inocidating with genuine small-pox matter, after 
the patient has had the disease some time before :f Fever does not always at- 
tend the small-pox, as in the case of nurses, who are infected on the arms, from 
children lying on them, who have the small pox; tliis is true after inoculation 
also: The pustule produced by inocidating persons who have had the small- 
pox, does not always produce fever; yet persons will take the genuine disease 
from inoculation with the matter taken from it: 

The second inoculation then runs its course more rapidly, being as far advanced 
by the third as the genuine is by the fifth day; it is sometimes followed by pain in 
the axilla, shght fever very early on the fourth or fifth day, and sometimes later: 
the water formed in the incisions soon dries up, and the elevation, hardness, 
and extent of the tumor round the incisions, in those who have had the small- 
pox before, when in the highest degree, are never equal to those who are ca- 
pable of receiving the infection at first: The inflammation comes on early, 
increases and subsides by the time the eruptive fever appears in the primary 
inoculation; and when in the primary inoculation, the inflammation of the in- 
cision advances gradually till the time of the eruption, it is known to be a case 
of secondary inocvdation by the subsidence of the tumor and hardness begin- 
ning to decrease at that time; whereas, in the primary inoculation, the fever, at 
the time of the eruption, is much more vehement, t 

When the patient has been inoculated, Huxham advises the feet and legs to 
be soaked in warm water for a short time, for several days before and after the 
appearance of the eruption, in order to determine the blood more to the feet; 
he states that it prevents the appearance of many pustules and much inflamma- 
tion about the head and face, wliich, as in erisypelas, is more dangerous about 
the head than any other part: The pustules are in consequence much more nu- » 
merous about the feet: The warm bath also, he thinks, lessens the fever: So 
strong is the eflfect of heat thus applied, that it induces pains in the legs; for on 



* Huxham, p. 133. London 1788. f Quier's letters on the success of inocu- 
lation at Jamaica, p. 90. 1778. t Quier on the Small-pox. 



214 OF THE SMALL-POX. 

the application of cataplasms severe pains are produced in them: The appli- 
cation of lead water, to the face, head and breast, or simple cold water fre- 
quently would prevent the eruption in these parts; indeed the cold affusion 
generally would be proper to lessen the fever where it rose hig-h: It might, 
however, in the weak and debiUtated have a bad effect: If the fever is very 
considerable and the eruption does not regularly advance, he advises the warm 
bath to the whole body: The fever having continued six days before the erup- 
tion appears, the warm bath or the vapor bath has then a good effect, c. 



( ~^15 ) 



CHAPTER X. 

CHICKEN-POX, COW-POX, AND MODIFIED SMALL-POX. 

Early Opinions regarding Varicella.^-Controversy respecting 
its Identity with Small-pox. — Varicella Lymphatica. — 
Varicella Variolodes, — Diagnosis of these disorders. — Of 
Coiv-pox. — Its introduction by Jenner. — Progress of the 
Vesicle. — Surgery of Vaccination. — Small-jyox and Cow- 
pox occurring together, or after each other. — Characters of 
modified Small-pox. — Causes of Small-pox after Vacci- 
nation. 

EARLY OPINIONS REGARDING VARICELLA. 

From the earliest periods at which small-pox was noticed, we 
read of a mild eruptive disease, liable to be confounded with it, 
but not preventing it; and consequently demanding attention 
with reference to diagnosis. This has gone by the several names 
of chrystalli, variolse lymphatic3e, spurise, volaticae, and pusilla3. 
By Riverius it was called varicella. Morton adopted from the 
vulgar, and introduced into medical language the term chicken- 
pox. The descriptions of this disease, which have been given 
by different authors, and their pathological views concerning it 
and its relation to small-pox, differ materially from each other.* 
It is clear that, acknowledging the necessity of diagnosis, they 
have yet failed in establishing it satisfactorily; for after the lapse 
of nine hundred years, the subject is declared to be so obscure 
as to demand fresh investigation. 

For the last fifty years, authors have been in the habit of 
drawing their notions concerning varicella from the paper pub- 
lished by Dr. Heberden, in the first volume of the Transactions 
of the College of Physicians of London. The points of doc- 
trine which he principally set forth were, that the chicken-pox 
arose from a specific contagion, affected the same individual but 
once during life, afforded no protection from small-pox, and was 
capable of being communicated by inoculation. It does not ap- 
pear, indeed, that he ever witnessed inoculation in this disease; 
but in his description it is implied that it has been so propagated, 
although by mistake, and that an eruption followed which has 

* See Cross on ** The Variolous Epidemic of Norwich," in 1819. Part 2, 
Chap. 2. Sketch of the History of Varicella. 



216 CHICKEN-POX, COW-POX, AND 

passed with inexperienced and hasty observers for the small-pox, 
from which however it does not secure the constitution. Dr. 
Willan, in 1S06, bore testimony to the general accuracy of Dr. 
Heberden's description. He detailed the appearance of the erup- 
tion with more precision, but coincided in opinion that it is a 
contagious disease, aflfording no protection from small-pox, and 
communicable by inoculation. 

CONTROVERSr RESPECTING ITS IDENTITY WITH SMALL-POX. 

More recent observations have tended to show that some mis- 
take has crept into the views of these authors concerning the pa- 
thology of varicella. It has been rendered highly probable that 
the genuine varicella is not communicable by inoculation;* but 
it has at the same time been shown, that many cases of supposed 
varicella do produce a disease by inoculation, which is not 
chicken-pox, but small-pox. Reasoning from these data, some 
modern authors have retained the notion of the specific disease 
varicella, but have given it new characters; while others have 
revived a doctrine which prevailed very generally in former 
times, and was distinctly avowed by Sauvages; viz. that chicken- 
pox and small-pox originate in one and the same contagion, and 
that varicella is indeed what its name imports, a mild, imper- 
fect, or modified form of variola. In support of the latter 
opinion, many ingenious arguments have been brought forward 
in a work, which has certainly thrown much light upon the his- 
tory of the eruptive diseases, connected in their origin or symp- 
toms with variola, t The true solution of the difficulties which 
have encumbered this branch of pathology, appears to be this. 
There are two diseases distinct from each other in their origin 
and character, both of which have been designated by the title of 
varicella. The one is the varicella lymphatica, the true or genu- 
ine varicella, as described by Mr. Bryce. The other is the va- 
ricella variolodes, partaking more decidedly of the nature of 
small-pox, and from which true small-pox may be obtained by 
inoculation. These distinctions I shall keep before me in the 
remarks now to be offered. 

The distinctions laid down in the two terms varicella lymphatica and varicel- 
la variolodes appear to cover the whole disputed ground, and stite in so many 
words, the shades by which the chicken-pox approaches the g-enuine small-pox. 

The arguments adduced by tlie believers in the identity of tliese diseases 
are, we believe, conclusive; they are founded upon the numerous varieties of 
small-pox which run insensibly into those of the varioloid, and admit of insen- 
sible gradations from the confluent to the mildest small-pox, and from that to 
chicken-pox; no distinct line can be drawn, on which a specific diflerence can 
he established between them; thus with regurd to the fever; its duration and 
severity are from the shghtest possible dcjji-ee, or no fever at all, up to a con- 

• BnTi E. Ed. Med. and Surg". Jonrnal, vol. xiv. p. 4G7. 
t Thomson's " Account of the Varioloid Epidemic of Scotland," London, 
1820. 



MODIFTF.n SMAI.T.-1M)X. 2U 

tinuancc of three or more days. The chicken-pox, the mildest vai-iety, some- 
times has considerable fever from one to three days:* Moore, who believes in 
the distinct natiu'c of these two diseases, says, tluit the fever of varicella and 
small-pox are nearly the same in symptoms and duration;! convulsions usher 
in the former as well a.s the latter; vomiting and delirium also occur in it; in 
the varioloid disease, the eruptive fever also is sometimes equally severe 
as in small-pox, and sometimes less so than in cl)icken-pox:t The small-pox 
we have seen attended with no fever at all, or a very slit^htonc, its in the case 
of secondaiy inoculation, formerly mentioned, and yet the diseiuse is attain com- 
municated from it by inoculation : It was then stated, that the pustule from secon- 
dary inoculation completes its course by the ordinary time of maturation of the 
primary pustule, and is often as far advanced on the third day as the pri- 
mary inoculated pustule is on the fifth :§ In the varioloid they partake of all 
deg-rccs, from pustules whicli run their course in two days to eig-lit; this I have 
seen; the experiments of Dr. Dan-ach shew thattlie same is true with reg-ard 
to the vaccine; a pustule which runs its course much sooner tlian eight days 
will communicate the genuine disease :I1 The vaccine also sometimes has pus- 
tules difluscd over the body, as the small-pox, varioloid, and chioken-pox 
have:^ and sometimes, though rarely, a succession of pustules.** The ap- 
pearance of successive crops of vesicles sometimes characterizes the small- 
poxj-f in Edinburgh; it has also been scentt in tlie varioloid by Cross at 
Norwich, and in chicken-pox it is also common: The other qualities, the uni- 
formity of the variolous and varicellous eruption in the vaccinated and in the 
unvaccinated, do not hold good; the chicken-pox appears ec^ually in the vac- 
cinated and in the unvaccinated: The variohjid follows vaccination and small- 
pox, and exhibits fair specimens of the latter in some instances;§§ wliichwillbe 
readily believed when the small-pox itself exhibits examples of pox in various 
degrees of progress, appearing late and maturating at the proper time, or not 
maturating completely,!! II from vesicles formed of simple elevations of the cuti- 
cle, to full pox, in the dificrent parts of the skin of the same individual: The 
distinct, severe, and even confluent small-pox follow tlie vaccine :^^ With re- 
gard to the want of depression in the centre of the vesicle in small-pox, this 
occurs also in varioloid, and sometimes in tlic chicken-pox:*** As to the fall- 
ing down of the vesicles on letting out the inclosed fluid, this takes place 
equally in small-pox, varioloid, and chicken-pox; the fact above mentioned, 
that all tlic varieties occur in the same skin, without factor, stopping at the 
pellucid state, and nev-er maturating nor forming an areola or slough, is a suf- 
ficient-}-j-| answer to all the arguments that can be brought to prove that these 
tliseases are different: the greater dimensions of the vesicle at the summit than 
at tlic base; the want of depression in the centre of the vesicle, and the w^ant 
of hardness and prominence formed in the skin at the base of the pox, are 



• Thompson on .Varioloid. 

\ See Bell on Vaccination, in New York Med. and Physical Journ. vol. iv. 
p. 154, quoting Moore's Hist, and Practice of Vaccination, p. 99. 

i Thompson, Cross, Bent, pougens, quoted in New York Med. and Phys, 
Journ. vol. iv. p. 455. 

§ Quicr on the Small-Pox in Jamaica, p. 77-78. 

B Exjjts. in Philadelphia Jotirnal for 1824. 

^ New York Med. and Phys. Journ. vol. i. p. 329. 

** See Dr. Post of New York, also Drs. Roger:3 and Pendleton's case* iu 
New York Med. and Phys. Journ. vol. i. p. 320— IPi. 

■j-f See Quier on the Small-Pox of Jamaica, p. 82. 

It Bell on Vaccination, in New York Med. :ukI Pliy^. Journ. vol. iv. p. 457 

§§ Thompson and Cross passim, an^l the e\peri<.iK-e of all prnctitioncr« 

U See Cross, p. 120-139. ^"i! Sc< Cro.s^. p- ('0- (.1 

*** Sec Cross quoting Miuirv), p 167 

fif See Cross, p. Xo^. 

Vol. ;i.— 2S 



218 CHICKEN-POX, COW-POX, AND 

common both to the varioloid and small-pox:* the tubcrcidar elevations, which 
succeed to vesicles and jiustule.s, occur most frequently in natural small-pox, 
but, says Professor Tliompson, they are sometimes present jn pustules of the 
chicken-pox: The indented character of the vesicle is found at times in all the 
varieties. In fine, the supposed peculiarities of each are found in all the others. 

C. 

VARICELLA LYMPHATICA. * 

The eruptive fever of varicella lymphatica is very slight, 
and rapidly followed by an eruption which is distinctly vesicu- 
lar from the earliest period. The vesicles when first seen are 
about the size of a split pea, perfectly transparent, and covered 
only by a cuticle as thin as that raised by a scald or blister. On 
puncturing them a clear lymph is evacuated, and they neither 
exhibit a cellulated structure nor a central depression. The 
eruption commences on the breast and back, and subsequently 
extends to the face, scalp, and extremities. On the second and 
third days of eruption, an irregular circle of inflammation sur- 
rounds eacli vesicle. The disease is attended, especially in chil- 
dren, with an incessant tingling or itching, which leads them to 
rub off the tops of the vesicles, so that the characteristics of the 
disorder are often destroyed at an early period. Even if the 
vesicle remains unbroken, the contained fluid becomes opaque 
about the fourth day, at which time the disease is in many cases 
with difliculty distinguished from small-pox by the eye alone. 
The vesicles are nearly always distinct. One case of confluent 
varicella, however, has been described by Mr. Ring. On the 
fifth day the vesicles appear covered with slight crusts, which 
are yellowish, scaly, and irregular, lying flat upon the surface 
of the body. In a very few instances only, have they been suc- 
ceeded by pits. Dr. Willan and others have noticed that the 
vesicles of the chicken-pox do not all appear in one day, but 
follow each other in successive crops. This, however, cannot 
be urged as a diagnostic mark of the disease, for it occurs also in 
the modified small-pox. 

VARICELLA VARIOLODES. 

Such are the distinguishing characters of varicella lymphati- 
ca. If the eruption, instead of being vesicular, exhibits in its 
early stages the appearance of indurated basis, — if the vesicles 
have a central depression, — if, after discharging their contents 
on the third day, a firm tubercle be found below, — and if the 
crusts which succeed are compact, defined, of a clear horny 
smoot.hness, and elevated, the disease was the varicella va- 
riolodes, and arose fioin the contagion of small-pox. All 

• See 'rhom])8()n on Varioloid, and Cross on tlie same disease, for proofs oi 
these facts. 



MODIFIKD SMALL-POX. 219 

authors are agreed that the former, or genuine varicella, afibrds 
no protection from small-pox. It is generally admitted also, that 
it sometimes spreads epidemically (as in schools); and hence 
some are inclined to attribute it to specific contagion. It is not 
now however contended by the best authors, that this contagion 
is communicable by inoculation, or that the disease affects an in- 
dividual once only during life. I am not aware that varicella, 
in this its vesicular or genuine form, has ever been met with in 
adult persons. It would appear as if the delicate cuticle of in- 
fantile life was indispensable to its development. 

The chicken-pox being a very slight disease, it is unnecessary 
to add any thing respecting its treatment. 

cow-pox. 

The introduction of cow-pox into general notice, is an event in 
the history of medicine too interesting to be passed over without 
some comment. The merit of the discovery rests wholly with 
Dr. Jenner, who made his first decisive experiment in 1796, 
and two years afterwards published his account of the variolas 
vaccinae^. The practice of vaccination was eagerly adopted by 
ali classes of persons in this country, and has since spread with 
astonishing rapidity over every quarter of the globe. The conse- 
quence has been the almost complete extermination of the small- 
pox from some countries, and a most important diminution of 
its malignity in others, where that desirable event has been im- 
peded. 

It has been satisfactorily shown, that there is an affection of the 
hoof of the horse in every respect the same with that of the ud- 
der of the cow, from which the term cow-pox has been derived. 
Both the one and the other are communicable to man by inocu- 
lation. The disease thus produced has the curious property of so 
modifying the human constitution, as in many cases to remove 
altogether the susceptibility of small-pox contagion, or failing in 
this, to secure at least the individual from the dangers of that 
formidable malady.t 

The cow-pox is a disease deserving of investigation, on ac- 
count of its great importance to mankind. It has its laws, charac- 
ters, and anomalies, as well as other diseases of more urgency; nor 



* The date of this puhlicatlon is June, 1798, 

"t" Some experiments have been made by Mr. Woodvillc and Mr. Coleman 
which did not succeed in producing" the vaccine disease from the matter of 
Grease; others, however, have since been instituted, and with success, proving 
Dr. Jenner.'s opinion. t Dr. Carpenter of Lancaster county, (Penn.) inocu- 
lated a cow with the matter of small-pox and protluced the vaccine. This 
source is more probal)le than any other. C. 

± Med. and Physical .Tournal, vol. iv. p. 381 and 466. 



220 CHICKEN-POX, COW-POX, AND 

can a practitioner judge correctly of the progress of vaccination, 
or pronounce with any confidence as to the security which it 
gives, unless he has studied the subject in its various details, and 
inquired into the sources of fallacy, and the modifications of 
which tlie disease is susceptible. Our experience in cow-pox is 
indeed still very limited. It has been only known for about 
thirty years, and it would be hazardous to say, that we are even 
yet acquainted with all its peculiarities. Viewed in this light, 
it cannot therefore be a matter of surprise, that the opinions 
now entertained by pathologists on the influence of vaccina- 
tion differ, in some respects, from those of the early writers. 

PROGRESS OP THE VESICLE. 

The cow-pox is communicable only by inoculation, and has 
seldom been known to occur twice to the same individual in that 
regular form, such as it is my object now to describe. After 
twenty-four hours the punctured point begins to inflame, and by 
the help of a microscope, a small vesicle with a regularly rounded 
edge may be observed to arise. This on the third day appears to 
the naked eye as an elevated point. By tlie fifth day the vesicle 
is quite distinct, and lymph may be procured from it. The 
lymph is transparent, and like the matter of small-pox, is inclos- 
ed in little cells. On the eighth day, an areola or inflamed cir- 
cle of about an inch and a -half radius, begins to form around the 
vesicle, which is now in its most perfect state. On the tenth day 
the areola is at its height, and the vesicle is pearl-coloured, per- 
fectly circular, and well elevated. As the inflammation fades, 
it leaves one or two concentric red circles, which continue visi- 
ble fiar two or tlu'ce days. On the fifteenth day the vaccination 
may be considered as completed. The lymph in the mean time 
becomes muddy and dark, and ultimately desiccates into a ma- 
hogany-coloured crust, which drops off towards the end of the 
third week, leaving behind it a small, circular, cellulated, and 
indented escliar, with a well defined border. 

During the formation of the areola, it is often stated thatsymj)- 
tomatic fever may be observed in cliildren, and this has been 
held out as a test of perfect vaccination; but the fact is (|uestiona- 
ble, and in vaccinating a(hilts, it is certainly not met with. The 
true test of the constitution being ailbcted is the regular progress 
of the vesicle. But this may be interrupted in several ways. It 
may pass through its stages too quickly to saturate the system 
effectually. The vesicle may be injured by accident, or by be- 
ing rubbed. An erysipelatous inflammation may come ujion the 
arm, and take place of the true areola, and i)us may be formed 
instead of vaccine lymph. The system may be j)re-occujiied by 
some chronic cutaneous disease, by diarrhoja, fever, or some ac- 



MODIFIED S MALL-POX. 221 



tivc internal inHammation. Lastly, there exists in some children 
a constitutional indisposition to the cow-pox, not to he antici- 
pated. Under such circumstances great dilliculty is experienced 
in infecting the arm, and the vesicle, when produced, is slow in 
its progress, of small size, and surrounded hy an imperfect are- 
ola.* 

Of the interference of different fehrile diseases with the pro- 
gress of the vaccine vesicle, numerous instances have heen re- 
corded. The suspension of its progress might have been anti- 
cipated from the known facts of the reciprocal action of conta- 

• The symptoms of the spurious form are thus described by Sir Gilbert 
Blanc; — "Vesicle amorphous or uncertiiin; fluid often straw-coloured, or puru- 
lent; areola absent, indistinct or confused with the vesicle; scab formed pre- 
maturely." 

The details of tlie subject are indeed so diversified, that we must settle down 
into the opinion of one of the greatest friends of vaccination, that tlie only 
sure test of efficacy of vaccination is re-vaccination. 

Three varieties of irregulai-ity, are stated by Bateman to have been noticed 
in the pustules; viz: pustules, ulcerations, and vesicles of an iiregoilar form. 
The pustule 'wliich is produced instead of the regular vaccine vesicle, is like a 
common boil, occasioned by a thorn or any extraneous body sticking in the 
skin; it also throws out a premature efflorescence, which is seldom circumscrib- 
ed; it is of a conoidal form, and raised upon a hard inflamed base, "with difluse 
redness extending beyond it: it increases rapidly from the second to the sixth 
day, and is usually broken before the end of the latter, when an irregular, ycl 
lowish-brown scab succeeds.* Ul^e7'afion, occupying the place of a regular 
vesicle, must be obviously incorrect ; it probably originates from the pustules 
just mentioned, which, on account of the itching that is excited, are sometimes 
scratched off" at a very early period; or, being prominent and tender, are readi- 
ly injured vand exasperated by the friction of the clothes, Scc.f 

With respect to the irregular vesicles, "which do not wholly secure the con- 
stitution from the small-pox," Dr. Willan has described and figrired three sorts. 
*' The Jirst is a single pearl-coloured vesicle, set on a hard dark red base, 
slightly elevated. It is larger and more globate than the pustule above repre- 
sented, but much less than the genuine vesicle : its top is flattened, or sometimes 
a little depressed, but the marg^in is not rounded or prominent. — Tlic second 
appears to be cellular, like the genuine vesicle; l)ut it is somewhat smaller, and 
more sessile, and has a sharp angulated edge. In the^r6-;f the areola is usually 
diflTuse, and of a dai-k rose-colour; in the second, it is sometimes of a dilute scar- 
let colour ; i-adiated, and very extensive, as from the sting of a wasp. The 
areola appears (earlier) round these vesicles, on the seventh or eighth day after 
inoculation, and continues more or less vivid for three days, during wliich time 
the scab is completely formed. The scab is smaller and less regular than 
that which succeeds the genuine vesicle ; it also falls off" much sooner, and, 

• Tliis premature advancement was pointed out by Dr. Jenner as a charac 
teristic of the irregidar pock, in his Paper of Instructions for Vaccine Inocula- 
tion, at an early period of the practice. He also justly remarked, in respect 
to the ♦' soft, amber-coloured" scab, left Ijy these {justules, that ''purulent 
matter cannot forni a scab so hai-d and compact as limpid matter." loc. cit. j). 
99, note. In other words, tliat the scab succeeding ix jnintult is less hard and 
compact than the scab which forms on a vasick. 

t Dr, Willan, loc, cit. 



222 CHICKEN-POX, COW-POX, AND 

gious fevers upon each other; but not only is vaccination retard- 
ed by these disorders (measles, scarlatina, chicken-pox, typhus, 
pneumonia, and the influenza), but it is occasionally rendered by 
them altogether inefficient. 

These considerations point out the propriety of paying minute 
attention to the process of vaccination, of preparing the body, in 
some instances, for its reception, and of keeping the system, dur- 
ing its progress, free from inflammatory action, in the manner 
formerly practised in inoculation for the small-pox. It requires 
no argument to prove, that a process which is io free the consti- 
tution from a poison so active and subtle as that of small-pox, 
should be conducted with at least as much attention as was paid 
to its introduction into the system. 

Besides the advantag-es resulting- from tlie vaccine in exhausting the suscepti- 



when separated, leaves a smaller cicatrix, which is sometimes angiilated. — The 
third irregular appearance is a vesicle without an areola."* 

It is further stated by Bateman, that the lymph of the vaccina vesicle be- 
comes altered in its quahties soon after the appearance of the inflamed areola; 
so that, if it be taken for the pui-poses of inoculation after the twelfth day, it 
frequently fails to produce any effect whatever, and in some cases it suddenly 
excites a pustule, or ulceration, in others an irreg-ular vesicle, and in others 
erysipelas. If taken when scabs are formed over the vesicles, (as in tlic case 
of the pustules of small-pox,) the virus is occasionally so putrescent and acrid, 
that it excites the same violent and fatal disease, wliich arises from slig-ht 
wounds received in dissecting- putrid bodies. 

This last circumstance has never occurred to our' knowledg-e in this country; 
on the contrary, the recommendation g-iven below for taking- the matter from 
the dried scab is not only safe, but it is effectual, and is found the best mode 
of preserving the matter from one season to another. 

Re-vaccination becomes imperatively necessary, when tlie regular vaccine 
pock is injured by rubbing- or by accident — where tlie system is pre-occupied 
by any other disease, and where the scar is feeble and not indented.f 

• It appears to me that Mr. Bryce, in liis able and valuable work on tlie 
Inoculation of Cow-pox, has, without any sound reason, impugiied these 
observations upon the "irrcg-ulai* vesicles," and considered the introduction 
of tlie terms as productive of "much injury to the true interests of vaccina- 
tion," and as sening- to screen igniorance or inattention in the operator:" and 
that his own reasoning-, which amounts to nothing- more than a hypothetical 
explanation (and consequently an admission) of the fact, is irrelevant. He di- 
vides the whole " into constitutional and local;" but at the same time admits, 
that he knows no criterion by which they are to be distingiiishcd, save tlie ul- 
timate seciu-ity ag-ainst small-pox produced by the one, and not by the other. 
(Appendix, No. x. p. 114, edit. 2d.) Now this is surely to screen ig-norance 
and inattention, by representing- minute observation of appcai'anccs as unneccs- 
ry. However, he more than compensates for tills error of logic, by tlie Ingeni- 
ous test of a doiiide inoculation, at \\\v interval of five or six days, which he li;is 
established, and whlcli is sulliciently mechanical, to be cmjjloyed without any 
unusual nlcet) of ol)servatl()n or tact. — JJuicman's tSi^nopais, p. 205-6. 

f Cross on the varioloid. 



MODIFIED SMALL-POX. 223 

billty to the small-pox, it also is useful as a remedy in many diseases: it has 
cured oljstinate ulcei-s on tlie arms and chest, by inoculating" their surfaces with 
the vaccine iciior; after which they become covered with awliite film, suppui-ate, 
and heal: a glandular tumor has been vaccinated in four or five places, and it 
has g-ot completely well. Scrofula, cnlarg-ement of the spleen, the result of 
miajimata, and rheumatism, liave all been cured by it.* 

SURGERY OF VACCINATION. 

The followin«^ appear to be the most important circumstances 
which merit attention in conducting the process of vaccination. 

The child should be in perfect health, and not less than two" 
nor more than six months old. The lymph should be taken from 
a vesicle of the seventh or eighth day.t It is desirable in all 
cases to insert six or eight punctures in the arm, as the system is 
probably thereby more completely saturated^ without any risk 
of severer inflammation ensuing. An ample supply of lymph is 
thus ensured; and it is a good practice not to inoculate above two 
or three children from the same vesicle, lest \he frequent appli- 
cation of the lancet should cause the exudation of common se- 
rum, unimpregnated with the specific matter of the disease. The 
skin should be perfectly tense, and the lancet sharp. When the 
areola is beginning to subside, it is advisable to exhibit a few 
doses of rhubarb and magnesia. Great care should be taken that 
the vesicle be not rubbed nor injured in any period of its course. 

SMALL-POX AND COW-POX OCCURRING TOGETHER. 

I proceed to detail the phenomena presented by the occurrence 
of small-pox, natural or inoculated, with cow-pox. They appear 
to point out some analogy existing between these diseases, which, 
coupled with other circumstances, may well justify Dr. .Tenner 
in having given to the latter the title of variolse vaccina. 



* Cross on vaccination. 

■\ It is taken in this countr}' between the sixth and the ninth day of the pustule; 
it will however succeed, when taken frora the scab, by wetting- it with water : 
The scab is effectual, if sealed up and preserved from the air, for more.than a 
year after the removal from the body: Infection is thus sent from Eng-land to 
the Mediterranean, and succeeds perfectly after many months: The scabs 
should also be kept as much as possible from heat and also from moisture: If 
the matter is used it should be taken on g-lasses, one-fourth of an inch square, 
and suflfered to diy perfectly before it is put awuy. The activity of the matter 
is so great that the fluid of one pustule mixed with a quarter of an oz. of water 
produces a pock as distinct and perfect as if the pure matter was used ; the 
effect also upon the constitution is equally perfect:* The punctures should be 
superficial — bleed little — and to secure its success, any hig-h degree of inflam- 
mation must be stopped by cold applications to the arm. In order to prove 
the constit\ition, it is necessary to re-vaccinate ; if the pustule then does not 
take effect the matter used is good: its failure is a sufficient proof of its efKcacv. 

C." 
* Thomas' Practice, p. 26S. 



^24 CHICKEN-rOX, COW-POX, AND 

Dr. Willan found, that by inoculating with variolous matter at 
diflerent periods, not exceeding a t^/'ceA", from the insertion of the 
vaccine lymph, small-pox followed. The eruption thus produced 
may appear as late as the fifteenth day of the vaccination, but the 
disease is milder and shorter in its course than usual, and it is 
■modified in its appearances. In the case of natural small-pox, 
the sixth is the latest day at which it can appear after vaccina- 
tion, so as to go through a severe and regular coiirse. If it occur 
at a later period than this, it is generally modified; and this mo- 
dified or imperfect variolous eruption was, in the early history 
of vaccination, often mistaken for an eruption from the vaccine 
virus. Many errors, indeed, have arisen from an ignorance of 
the phenomena that attend the combination of these two diseases. 
Their influence is reciprocal. If the eruption of the small-pox 
takes place before the areola begins to form around the vaccine 
pock, the latter loses its regular character, while the eruption of 
small-pox follows its usual course. If vaccination be practised 
immediately preceding or subsequent to the eruption of small- 
pox, the vaccine vesicle does not come forward. By inocula- 
tion with vaccine and variolous matter at the same time, both 
diseases run their usual course. 

In this, however, there Is some variety; they sometimes modify each other; 
sometimes the vaccine and sometimes the variolous matter takes elfect. Experi- 
ments have been made upon the subject, by Woodville, Willan and Fergiison. 

Dr. Woodville in 1799 vaccinated 510 patients in the small-pox hospital witli 
vaccine virus, and produced in the greater number a g-eneral eruption ofvario- 
lous-likc pustules, instead of the vaccine pustule. Dr. Jenner thoug-ht that 
this result was to be attributed to the atmosphere of the hospital, wliich vario- 
lated them. 

Dr. Woodville then mixed the variolous and vaccine matter and inserted it 
into the arms of twenty-cig-ht persons: In one-half the small-pox, in the other 
the vaccine was produced: but in none were there many pustules nor much in- 
disposition. These two diseases were no doubt the varioloid or modified small- 
pox; and from Dr. Woodville's observations were a perfect security against the 
small-pox: Dr. Willan also coincided with this idea; it has accordingly been 
proposed to inoculate with the vaccine, and when the pustule has taken effect, 
to insert in another part tlie smull-pox matter; they will botli then go on toge- 
ther and secure tlie system completely from further attacks. By this plan, the 
doul)ts* of the upper classes witli regard to vaccination will lie avoided; as also 
the prejudices of the lower, and the patient be perfectly secured. If the pus- 
tule of the vaccine and tlie van(;la are placed so nc:ir together that they run into 
each other, the matter taken from the vaccine siile of the pustule produces the 
vaccine — that from tlie variolous side tlie small-])ox. It is said that when the 
vaccine disease is taken immediately from the cow , it sometimes produces pus- 
tules and a high degree of fever; subsequent inocuhitions witli the same matter 
are not attended with these effects. When any inilanimatory and dangerous 
symptoms occ\ir, they may be referred to the matter having been bad, or to 
some defect of constitution in the individual at the time. C 

Such arc; the principal phenomena which arc presented by 
small-pox and cow-pox occtirrinii; toiiether in the same indivi- 
dii'd. A superior interest lias lately attached to the occurrcnci; 



MODlKir.l) SMAIJ.iMJK. 225 

of these diseases after cacli other, at distant periods, particularly 
to iliat of small-2)0x after vaccination. 

CHARACTER OF MODIFIED SMALL-POX. 

The cow-pox had not long been introduced, before it was as- 
certained that the preventive power of the vaccine virus was not 
perfect; and every year's experience. serves more and more to 
show, that a certain proportion of those who have undergone 
vaccination will take small-pox at a subsequent period of their 
lives. The circumstances under which this occurs, tho causes 
to which it may be ascribed, the proportion of vaccinated sub- 
joets thus aflected, and the characters of the disease so produced, 
iiave lately excited much attention, and they will require to be 
rapidly sketched in this place. 

MODIFIED SMALL-POX. 

The characters which small-pox presents when it occurs sub- 
sequent to vaccination, have been detailed with great minute- 
ness by various authors, chiefly with the intention of establishing 
the diagnosis between it and varicella; but the view which we 
have taken of that disease w^ill preclude the necessity of equal 
precision here. Small-pox has sometimes occurred after vacci- 
nation in its most perfect and genuine form, but in by far the 
larger proportion of instances, it is modified either in the aspect 
or progress of the pustules. So completely altered indeed is the 
appearance of the eruption, on some occasions, by the influence 
of previous vaccination, and so extremely mild is the character 
both of the fever and of the eruption, that the true nature of the 
disease could never have been suspected by one who had not ob- 
served it in a variety of instances, and marked the insensible gra- 
dations by which its characters run into each other. The initia- 
tory fever is generally severe, but in almost all cases recedes 
entirely on the appearance of the eruption. The pustules are 
often hard or horny, but scarcely ever fail to exhibit the diag- 
nostic mark of variolous eruption, depressed centres. They run 
through their stages v/ith rapidity, maturating for the most part 
on the fifth day. 

That this disease is a modified form of variola there can be no 
doubt, and in strict conformity with the language of the old au- 
thors we may call it the varicella variolodes. It follows expo- 
sure to variolous contagion; in its severer form it is capable of 
communicating the cr/5i^«/ small-pox, and even the mildest varie- 
ties of it will, in the unprotected, produce genuine small-pox by 
inoculation. The danger attending it is very small. Mild as 
the inoculated small-pox is, small-pox after well conducted vac- 
cination, in the great majority of cases, is even milder. In the 

Vol. it. — 29 



256 CHICKEN-PO^, COW-POX, kc. 

few instances where it has ended fatally, the result is attributabk 
to some accidental circumstance, sucli as its concurrence with 
diseased lungs, inflamed bowels, or scrofula, rather than to the 
common and acknowledged effects of small-pox. It may occur 
at any period subsequent to vaccination. It has been taken by 
persons who had previously exposed themselves with impunity 
to the full influence of the variolous contagion. It may be com- 
municated by inoculation, but it is received for the most part in 
the natural way. 

The disease has been by some ascribed to incomplete vaccina- 
tion, and the notion is probably in a grent degree correct; for 
though it has been observed in a few cases where the progress of 
the vaccine vesicle was to all appearance regular, yet it has rare- 
ly occurred to me to witness it in a severe form, where the cica- 
trix was perfect, that is, of moderate size, well defined, perfect- 
ly circular J and indented. Deterioration of the vaccine virus 
from successive inoculations has been brought forward by other 
pathologists as calculated to explain the occurrence of small-pox 
after vaccination. This opinion, however, is unsupported by any 
arguments; and is quite irreconcileable with the phaenomena of 
variolous inoculation. ^ As little foundation is there for the hy- 
pothesis of a spurious cow-pox, once formed to explain some of 
the anomalies which this disease presents. Taking all the evi- 
dence that has been afforded us respecting small-pox after vacci- 
nation, it appears that we must seek for its cause partly in the 
imperfect saturation of the system with the vaccine influence, 
and partly in that law of the animal occonomy which regulates the 
susceptibility of variolous contagion. Natural small-pox in its 
severest form does not always aftbrd protection from a subse- 
quent attack of the disease. To that peculiarity of constitu- 
tion which favours secondary small-pox, we must be content to 
refer those cases in which small-pox occurs subsequent io perfect 
vaccination. 

The proportion of the vaccinated who are subsequently affect- 
ed by small-pox in a well-marked form (for we may safely leave 
out of consideration the cases of mild varicella), is a point of the 
utmost consequence to determine, but no satisfactory conclusions 
can be drawn from the calculations which have hitherto been 
made. Upon this indeed must ultimately depend the fate of vac- 
cination; but no reasonable doubt can be entertained from the 
facts now before the world, that the proportion is such as not to 
affect, in any sensible degree, the credit of vaccination; which 
must continue therefore to uphold the fame of Jennef, and the 
triumph of medical art. 



< 227 ) 



CHAPTER IV. 

OF THE MEASLES. 



First */2ppearance and early History of the Measles. — Symp- 
toms and Sequelse of the Disease. — Pneumonia. — Phthisis. 
— Cancrum oris. — Putrid or malignant kind of Measles. — 
Peculiarities in the Contagion of Measles. — Prognosis. — 
Inoculation. — Treatment of the Disease. 

EARLY HISTORY. 

The Measles was introduced into Europe about the same time 
as the small-pox, and followed in its track. For a long time it 
was supposed to be only a variety or modification of that disease, 
and as such it is described by Hali Abbas and Rhazes. Diemer- 
broeck in 1687, and Morton in 1696, maintained i\\Q identity of 
small-pox and measles, nor was it until lately that the diagnosis 
was fully established. Sydenham described accurately the mea- 
sles which prevailed in London in 1670, and to his history of the 
disease very little has been added by more modern authors. For 
the few additions which have since been made, we are chiefly in- 
debted to Dr. Watson in 1763, and to Dr. Willan in 1800. Seve- 
ral species of measles have been described by nosologists, but they 
are all referable to one, — the rubeola vulgaris of Dr. Cullen: the 
other forms which measles assumes being only modifications of 
this, arising either from a peculiar condition of the atmosphere, 
or the constitution of the individual affected. 

SYMPTOMS. 

The measles commences with the usu^l symptoms oi pyrexia; 
nor is it at first to be distinguished from an attack of common 
continued fever. The diagnosis is to be effected by a knowledge 
of the prevailing epidemic, and attention to those catarrhal symp- 
toms which are the constant concomitants of the eruptive fever 
of measles. The mucous membranes of the head and chest are 
alike affected; the tunica conjunctiva, the Schneiderian membrane, 
and the mucous membrane of the larynx and bronchia. The eye- 
lids are swelled, and the eyes suffused, watery, and morbidly 
sensible to light; there is a copious thin secretion from the nose, 
with sneezing; and lastly, a dry cough, with hoarseness and 
some degree of dyspnoea. Besides these catarrhal symptoms, 



228 ^ or THE MEASLES. 

the eruptive stage oi' measles is marked by considerable heaviness 
of the head, and drowsiness, amounting in some cases almost to 
coma. The heat of the skin is great, the pulse frequent and 
hard, and the general marks of pyrexia severer than what occur in 
cases of common catarrh. The eruption usually shows itself on 
the fourth day from the occurrence of rigors, but it is sometimes 
delayed a day or two. Cases indeed have occurred where the 
previous catarrhal symptoms continued for eight days, or even a 
fortnight. 

In the epidemic, described by Watson, the eruptions appeared on the second 
day. Dr. Hazeltine, of Berwick, (Maine,) observed an eruption on the mu- 
cous membrane of the fauces for three days previous to the appearance of the 
measles, as also on the g-ums. White aphthous specks have also been seen in 
the mouth several days before the eruption, and even before any indisposition; 
These specks increased in size and were accompanied with erysipelas of the 
fauces and mouth, extending- down the pharynx.* Ptyalism sometimes accom- 
panies the hoarseness. Epileptic spasms also accompany the first symptoms; 
coma is so common as almost to amount to a distinctive trait. C. 

The eruption of measles first appears on the forehead, and gra- 
dually spreads over the whole body. It shows itself in the form 
of distinct, red, circular spots, which afterwards coalesce into 
patches of an irregular figure. The colour of the eruption is of 
a dingy red, very different from the vivid redness of scarlet fe- 
ver. It is sensibly elevated upon the face, and often also upon 
the breast and back, but scarcely ever upon the extremities. 
Upon the first appearance of the eruption, the catarrhal symp- 
toms and the accompanying fever sometimes subside completely, 
but this is by no means a frequent occurrence. Indeed they are 
often aggravated, so that upon the second or third day of the 
eruption it is not uncommon to meet with severe cough and 
dyspnoea, the measly catarrh merging, in fact, in acute pneumo- 
nia. The stomach too, in severe cases, is often very irritable 
during the first days of measles, with vomiting of bile, and exces- 
sive restlessness. On the second day the eruption on the face 
is most vivid, and as it declines on the face, is at its height on 
the extremities. In about five days it completely disappears 
from the whole body. A slight discoloration of the skin com- 
monly remains for a short time, which in some cases goes on to 
desquamation. 

The decline of the eruption is not always followed by the sub- 
sidence of the other symptoms. A considerable degree of cough, 
or difficulty of breatliing, frequently remains, marking the con- 
tinuance of that inflammatory disposition which characterizes the 
former stages of the disease. The ])ulse continues frecjucnt, and 
full; and in scrofulous habits of body this state of disease occa- 



Qulcr's account of the measles in Jamaica. 



OF THP: measles. 229 

sionally end in haemoptysis, hectic fever, and genuine consump- 
tion. All the sequelx of measles have an inflammatory charac- 
ter. Upon the decline of the eruption diarrhoea often comes on, 
and Sydenham was, I believe, the first to take notice that this 
frequently yielded to l)lood-letting. Among the other conse- 
quences of measles may be enumerated ophthalmia, ewellings of 
the lymphatic glands of the neck, chronic eruptions of a porrigi- 
nous character, discharges behind the ears, or affections of the 
bowels ending in marasmus. Inflammatory symptoms of an 
urgent kind often supervene when the practitioner is least pre- 
pared for them, and therefore a caution should be given to 
watch the patient attentively during the whole period of conva- 
lescence. 

Among the irregular forms of measles may be first noticed that 
species of th-e disease, called by Dr. Willan rubeola sine catar- 
rho. It is a very rare variety, and only interesting in a patholo- 
gical point of view.* The diagnosis is here, as might be expect- 
ed, very difficult, and seldom satisfactory until it has produced in 
another child the common measles, which it is capable of doing. 
The most remarkable anomaly which the history of measles pre- 
sents, is its occasional occurrence in a very highly aggravated or 
malignant form; and this not merely in individual cases, but even 
as an epidemic. Such a form of measles prevailed at Plymouth in 
1745, in London in 1763, and at Edinburgh, from September to 
December 181 6. t The symptoms of the eruptive stage, in these 
epidemics, were unusually severe. t Extreme debility quickly 
supervened, with restlessness, or sometimes coma, a disposition 



* Dr. Hosack saw this variety of measles In the year 1813 ; it was attended 
with but little fever, and often without any whatever; it appeared in those who 
had the measles, and those, who took it, had the measles afterwards. 

f Consult the Works of Huxham, and the Observations of Dr. Watson in 
the 4th vol. Med. Obs. and Enq. — See also the Ed. Med. and Surg-. Journal, 
January 1817. 

i The eyelids were much swelled, so that the eyes were with difficulty 
opened, the eye itself swelled and prominent; , the meatus auditorius also in- 
flamed; the cough hard and dry; when expectoration occurred the disease was 
mitig-ated; coma, delirium, or excessive headach appeared as the disease ad- 
vanced; the fauces were of a deep red colour^ as if the patient had angina ma- 
ligna; the tongue foul, and the stools very foetid: the eruption was often delayed 
till the fourth or fifth day, when typhus was apt to make its appearance. The 
duration of the eruption was various; if it appeared on the second day, it dis- 
appeared on the fom-th, or at most, on the fifth or sixth day; when it did not 
appear till the fifth day, or later, it was protracted to the twelfth, fourteenth, 
or twentieth day, assuming at different times a red, pale, livid, or black color.* 
The other symptoms appeared either in a more violent degree, or earlier than 
in the regular kind: Inflamation of the lungs was more common: Suppurations 
appeared in the car, eyes, brain, and other parts, and now and then were 
fatal. f Marasmus, phthisis, clu-onic diarrhoea, dropsy, caries of the bones, were 
also its sequcl?e. C. 

* Philip, vol. i. p. 438-9. t Ibid. p. 410-1. 



230 OF THE MEASLES. 

to vomiting, a dry, hard, or black tongue, and a deep red colour 
of the fauces, — typhoid symptoms, that is to say, with great irri- 
tability of the stomach. In these cases too, the eruption did not 
exhibit its usual appearances. It frequently receded in the course 
of the first twenty-four hours; and when it first appeared was less 
elevated than usual, and of a dark and livid colour. A large 
proportion of these cases proved fatal; and on dissection, mucus 
was found collected in considerable quantity in the bronchia, 
with other marks of inflammation or congestion within the tho- 
rax. In the epidemic of Edinburgh in 1816, the recession of 
the eruption was the worst symptom; few recovering in whom 
this occurred. It was neither attributable to cold, nor to the too 
free use of cathartics. It is commonly said, under these circum- 
stances, that the energy of the system does not prove sufficient to 
throw out the eruption. The more correct expression seems to 
be (and the phenomena of small-pox and scarlet fever give coun- 
tenance to this view of the case,) that when the mucous mem- 
branes are violently attacked in the first instance, metastasis 
to the skin does not take place, which under common circum- 
stances relieves them. 

Measles, like any other disease, varies in tlie general afTectionofthe system; 
in the measles of Edinburgh, the cases in which it occurred in the irregulai- 
form were tliose exposed to debilitating- causes, as bad air, miserable diet, and 
all those circumstances which produce typhus: Sometimes the fever appeared 
and ended in death, without any eruption: It exhibited nearly the same charac- 
ters as scarlatina in many cases, the livid colour and rapid recession of the erup- 
tion, the typhoid state, and the irritability of the stomach. 

Dr. Quicr describes an inflammatory variety of measles composed of the erup- 
tive and the dysenteric stages, with cough, Sec. The first symptoms were as 
usual; the extension of the inflammation down the alimentary canal introduced 
the dysenteric stage, wliich, if depletion had not been sufticiently used, ended 
in the common form of that disease, bloody stools, gripings, tenesmus and con- 
stant vomiting; a change of tlie erysipelatous inflammation into the phlegmo- 
nous, in the parts about the throat, also attended with incessant pain of the 
belly; inflammation, ulceration, gangrene of the intestuics, protrusion ofthe rec- 
tum, with biles all over the body, and an itchy eruption over the skin, were 
among the symptoms: Sometimes the disease was translated to the bnun: Some- 
limes tlie fever was constant during the day; sometimes it intermitted; dropsy 
also followed it: the most hearty, strong, and hale persons were the most sub- 
ject to it, whilst the weak and debihtatcd escaped almost without any disease. 

The lungs and intestines :ifter death exhibit in the measles, strong marks of 
inflammation, inclining even to sphacehis: and when death tikes place during 
the eru])tion, the trachea and its ramifications are covered with it. This form 
ofthe disease is described by Sydenham; it is produced particularly in adults 
by the use of a hot regimen, and is relieved by blecchng, and low diet: The 
eruptions by the too great use of stimulants, or warm clothing, grow black, and 
the lungs become highly inflamed. C. 

PECULIARITIES IN THE CONTAGION OF MEASLES. 

The measles arises iVoni a specific contagion, the latent period 
of which is about eight days, varying however to ten, or even 



OV THE MEASLES. 331 

fourteen. It has been disputed whether measles can be taken a 
second time. By some of the older authors its occasional recur- 
rence was admitted, but of late years the fact has been most sa- 
tisfactorily established. Dr. Baillie has described eight instances 
of the kind, and it is a singular circumstance that they occurred 
in individuals of the same family.* Dr. Willan has thrown out 
the suggestion, that where there are no catarrhal symptoms, the 
susceptibility of the disease is not removed. 

He states that the disease occurs sometimes in another spurious form, whi^li 
is also insufficient to protect the system from future attacks, as many persons 
thus affected who had the febrile, catarrhal, and eruptive symptoms took the 
<lisease a second time.f In Dr. Willan's cases, which occurred in his own fa- 
mily, the fact was clearly proved; the disease was taken a second time, in twa 
individuals; it was not therefore a sug-g-estion as the author states, but actual 
proof:t He also has observed that when the efflorescence without catarrhal 
symptoms has declined, a second appears with violent disorder of the constitu- 
tion, on the fourth day from its commencement. § Sometimes the fever appears 
without the eruptions, H also the contagion produces some of the symptoms of 
measles, without fever or eruption; Sometimes a second fever and eruption ap- 
pear after the first has disappeared: Burserius and Morton relate instances of 
its appearance a second time. 

The measles prevails generally during the spring months, and 
often along with small-pox. The circumstances which determine 
the severity of the disease in particular individuals are not very 
well ascertained, but it is certain that in scrofulous habits, and in 
those of a plethoric disposition, it is principally to be dreaded. 

PROGNOSIS. 

The prognosis is compounded of symptoms drawn from the general fever 
and the affection of the lungs; the more intense the fever, the more dry the skin, 
the harder, more frequent and fuller the pulse; and the more intense the other 
general and local symptoms the less favourable is the case.| Vhen the eruption 
is not ver)'' favourable, it sometimes leaves pits like those wuich follow small- 
pox: the eruption continuing red longer than usual is an unfavourable symp- 
tom. The more early and free the desquamation, the more favourable the case; 
a black or livid eruption indicates great dang'er; they are often the result of 
too heating and stimulating modes of treatment. When the fever abates on the 
appearance of the eruption, and ceases at the period of desquamation, leaving 
the patient free from cough and dyspnoea, the case can only be considered as 
safe;** a diarrhoea toward the end of the disease is always salutary; it may in- 
crease so far as to become dangerous. When the diarrhoea abates, when the 
skin becomes moist, the cough and dyspnoea lessen, the pulse becoming fuller 
and less frequent, the restlessness diminishing, the case is favourable, ff 



* Transactions of a Society for the Improvement of Med. and Chir. Know- 
ledge, vol. iii. pages 258 and 263. 

f New York Med. Rep. vol. v. No. 3. 

t Rep. on the dls. of Lond. 1799, p. 207. 

§ Dcscr. and treat, of Cut. dis. ord. iii. part i. 

T Quarin, quoted bv Philip, vol. i. p. 442. 

1 Philip, p. 431. 

** Ibid. 434-5-6. 

If T'liilip on Hie Mcnsle!^, 



232 OF THE MEASLES. 

Death in the more violent forms results from pneumonic or dysenteric disease 
mortification of the rectum, pudendum, and cheek have also occurred : Ulcera- 
tions of the jaws also take place: Some die of emaciation. Inflammation of the 
lung-s, adhesions, and sphacelations have also occurred. 

CANCRUM ORIS. 

The danger in measles principally arises from pneumonic in- 
flammation, but in very feeble frames, and in the lowest ranks 
of society, where cold and poverty combine with disease in re- 
ducing the powers of life, the dreadful spectacle of gangrenous 
erosion of the cheek is sometimes witnessed. This affection, 
commonly called cancrum oris, begins in the inside of the cheek 
by a hard swelling. The gums ulcerate and the teeth loosen and 
fall out; a black spot next appears on the cheek, or at the corner 
of the lip, which rapidly spreads, and the child dies miserably. 
Such a complaint sometimes accompanies the latter stages of 
small-pox, and infantile fever, and sometimes it occurs idiopa- 
thically, but its pathology is always the same. Medicine fur- 
nishes but very imperfect means of combating it. Tonics and 
local stimulants are indicated, but their influence is very trifling. 

INOCULATION. 

Dr. Home, of Edinburgh, informs us, that he succeeded in 
inoculating the measles, by applying over an incision in the skin 
cotton dipped in the blood of a patient labouring under the dis- 
ease. He states that the eruptive fever followed in six days, that 
the symptoms were mild, and the lungs not affected as in the 
casual disease. It does not appear, however, that these observa- 
tions have been verified by any later experiments.* It is satis- 
factorily ascertained that the measles delays the progress of vacci- 
nation, and of the pustule of the inoculated small-pox. Two 
cases however are recorded, by Dr. Russell, of small-pox and 
measles running their regular course in the same individual, at 
the same time.t 

TREATMENT. 

The treatment of measles, in its common form, must be regu- 
gulated chiefly by the symptoms which mark the tendency to 
thoracic inflammation. It is well ascertained that these are of- 



* Speranza has also succeeded in inoculatincj for the measles, by ])unct»iring- 
:i prominent mcasle, witli the lanot-.t, and inoculating with the blood. He 
succeeded in six cases.* 

I See also "Case of the simultaneous occurrence of Small-pox and Mr:i 
>»les," in tjjc Med. Ohir. Transa(:tions, vol. xiii, pag"c IGJ- 

* nihl. lt:diaua. 



OF THE MEASf.KS. 2.^'. 

ten aggravated by a free exposure of the body to cold, cither du- 
ring or previous to the eruption; and some have remarked, that 
this aggravation of the catarrhal symptoms is occasionally attend- 
ed by a recession of the eruption. Moderate warmth therefore 
is on all accounts advisable in measles. 

"It is necessary to be particularly careful not to exceed the feeling-s of com- 
fort in this respect. When the inflammatory symptoms run hig-h, tlie reduction 
of the temperature will be necessar\'i the report of the patient however should 
regulate this matter: Cool drinks are always proper in this disease, and a free 
ventilation, g-raduating" the temperature as above directed. 

The diet must be antiphlog-istic, as roasted apples, barley water, sago, tapio- 
ca, aiTow-root, linseed tea, oatmeal, or Indian gruel, and it should be g"iven in 
small quantities and often repeated." 

If, however, the patient be of a very delicate habit, the diet must not be too 
antiphlogistic, otherwise there is dang-er of typhus. Milk has been praised 
very much, particularly as it has a valuable effect in moderating the bilous di- 
arrhoea, when it is too profuse : With regard to the use of exercise, it must be 
regulated by the state of the fever; if the patient is inclined to lie in bed, he 
may do so; but in general, where tlie disease is mild, this will be unneces- 
sary. C. 

It has been imagined that active purging during the early stage 
has contributed to repel the eruption, and thus to increase the 
danger of the patient. This observation I have never been able 
to verify. On the contrary, saline purgatives seem well adapt- 
ed to diminish the inflammatory excitement which prevails 
throughout the whole course of the disease. In mild cases no- 
thing further is required than promoting a gentle perspiration, and 
exhibiting an occasional laxative. 

Where pneumonic symptoms prevail, a more vigorous prac- 
tice is necessary; but a distinction is here to be made, which Dr. 
Willan has placed in a very clear point of view. The oppres- 
sion of the respiration, and the cough which accompany the first 
appearance of this and of other eruptions, do not appear to de- 
pend on true inflammation, for they often go off suddenly, and 
they may, at any rate, generally be left to their natural termina- 
tion. But is upon the third day of the eruption, when the dysp- 
noea and cough become aggravated while the eruption is declin- 
ing, when the cough in particular is hard, and accompanied by 
pain in the chest, that an active system of treatment is required. 
Bleeding from the arm is then indispensable, and must be re- 
peated in proportion to the urgency of the symptoms. Even 
children of a tender age require in measles this evacuation, for 
which leeches and cupping afford but an imperfect succeuaneum. 
Children do not bear general blood-letting well, but they bear it 
better in measles than in almost any other disease. The imme- 
diate danger from pneumonia, and the more distant but not less 
alarming risk of phthisis, make it advisable to check the pneumo- 
nic symptoms in the speediest and most effectual way. 

Vol, it.— 30 



234 OF THE MEASLES. 

The remark of the excellent author, that chil(h*cn require to be bled in 
measles, is of the highest importance. It prevents and cures inflammations and 
congestions, obviates convulsions, diarrhoea, jmd most of the consequences of 
neglected or maltreated cases. We think, the remark applies to all fevers of 
high action in children, if the practice be scientifically regulated. 

That a state of measles accompanied by an abject state of debility does oc- 
cur occasionally and is to be treated by stimulants and tonics, no practitioner of 
much experience or theoretic knowledge can deny. It Is nevertheless true, 
that the author's apprehensions of death from debility, occasioned by the re- 
moval of local congestions, and inflammations in typhoid cases, are generally 
groundless. If these local affections continue, the patient must, but if they be 
removed he may die: but as tlie patient usually falls a prey to disorganization, 
it scarcely ever happens, that he dies of debility unconnected with the local 
aflrection. P. 

Saline and demulcent medicines are useful; opiates may be gi- 
ven with much advantage after bleeding and aperients, if the 
cough continues troublesome. A blister should be applied to the 
chest, but not until the strength of the pulse has been considera- 
bly reduced by local or general blood-letting. In the inflamma- 
tory sequelae of measles, blistered parts have often a strong dis- 
position to sloughing and gangrene. 

The warm bath is often a powerful assistant when the lungs are violently af- 
fected in this disease. Dr. Armstrong advises it liighl}' impregnated with 
salt. Dr. Lockyeralso praises the coldaflusion intlie inflammatoiy stagc'of mea- 
sles: it prevents the inflammatory afiections of the chest by the su]-)pression of 
the early excitement without any bad cff'cctsi on tliis subject, it will be proper 
to consult p. 99, et seq. of this volume. 

Upon the decline of the disease, if the pulse remains frequent, 
it will be proper to confine the patient to a very mild diet, and 
to direct a saline draught, with a few drops of tincture of digitalis, 
to be taken every six hours. 

The use ofantimonlals with nitre; or saline draughts, as the spirit of Mlndc- 
rerus, of saltoftiU'tar neutralized with vinegar, or the citric acid; (llaubcr'ssalt 
^ii. witli the sixth of a grain of tartar emetic every two hoiu's, will be proper 
throughout the inflammatory s^-mptoms; at night they ma} be continued uniting 
with them a little laudarmm to determine to the skin. The digltulis may also 
be combined with these mechclncs. It will not, liowever, answer so well in the 
first stiiges as blood-letting; and should not be relied on for the purpose of de- 
pletion, as it is slow in operating on tlio system. 

If diarrhoea occur it must not be suddenly suppressed; it will be found best to 
promote it by gentle saline cathartics, as it will favour the depletion of the sys- 
tem, and the removal of the inflammatory diathesis. In some instances bleed- 
ing will put a period to the inflamm:itory chiuacter of the symptoms, and also 
to the diarrhoea. When, however, marks of weakness or typhoid s} mptonis 
appear, it must be suppressed; for tills purpose chalk, kino, extract of logwood, 
catechu, in small doses will answer completely. 

Sometimes the erujitlon suddenly recedes, and is followed by spasms, con- 
vulsions, delirium, stui)or or great anxiety :uid restlessness. It must I)e immedi- 
ately restored, and for this jjurpose the use of the warm bath \\ 1th sinapisms to tlie 
breast and legs, and wine whey will be prt)pei-. The use of camphor and sul)- 
carbonate of tunnionia, e(iual pai-ts, to be taken in the dose of six grains every 
two hours will be found to he usefid; or sulphuric ather .:;i: — or c;u-bonate ol 
ammonia, one, two, or tlu'ce grains, according to cuv\nnstances; camphor, \^i: 
ii. every two hours will also be \uluablc, glvcai in a tabic spoonful of a solutic^ 



OF THE MEASLES. 235 

of the citrate of potash, or of the spiritus miiulcreri, nitre, grs. Xi or camphor, 
grs. iii. with subcarbonate of ammonia, may he i^ivcn to an adult every hour till 
the eruption appears* C. 

The convalescence of measles docs not bear the exhibition of 
bitter and tonic medicines, like that of many other febrile 
diseases. 

On the contrary it will generally be advisabl9 to kcci) the bowels open by 
saline purgatives, as it will prevent the appearance of pneumonic complaints, 
ophthalmia, the development of scrofula, dropsy, &c. which sometimes follow 
the measles: and if dyspncca, with hoarseness, loss of voice, or any sign of local 
inflammatory action appear, it will be necessary to bleed from the arm, or locally 
by leeches near to the parts inflamed, to use tlie warm bath, with some of the 
above sudorifics, to keep the patient quiet and easy and continue the low diet. 
The ophthalmia may be relieved by the acetate of zinc, gr. i. to the oz. of water, 
applied often to the eye, avoiding exposure to a strong light; poultices of bread 
and milk to the eyes may also be useful, and if they do not agree, the above 
cold lotion. C. 

When the measles assumes that malignant or typhoid form 
which we formerly described, recourse must be had to the warm 
bath, blisters, wine, and cordials; (aromatics, serpentaria, am- 
monia, ether.) The observations of Dr. Watson on the treat- 
ment of this form of measles are judicious, and applicable to dis- 
ease in a very extended view. If bleeding under these circum- 
stances be resorted to, as this author remarks, the patient loses 
more by the debility which is brought on, than is gained by the 
relief afforded to the circulation within the thorax. It may be 
remarked indeed generally, that in all typhoid fevers it is a point 
of great difficulty to determine, how far local congestions and in- 
flammations are to be relieved, at the risk of reducing too much 
the tone and powers of the system. The malignant form of 
measles sometimes sliows itself sporadically, that is to say, in 
individual cases, while the general character of the epidemic is 
inflammatory. The circumstance may generally be traced to 
the weakened condition of the child, the result probably of fever, 
hooping cough, scrofula, or some other preceding disease. 
Such cases seldom end happily, notwithstanding the most judi^ 
cious practice. 

In the epidemics described by Watson and Quier, diflferent plans were pur- 
sued; though blood-letting was necessary in tlie first stage of the n\;dignant 
measles, described by Dr. Watson, yet in the second after tlie febrile heat and 
eruption had gone, though the difliculty of Ijrcathing continued, it could not 
be borne; on the contrary, it increased the dclnlity to an alarming degi-ee. In 
the second stage, therefore, bleeding he considered as highly dangerous: local 
bleeding from tJie chest may, in sucli cases, be useful. Dr. AVatson found that 
after bleeding, tai-ti-ite of antimony in small doses, so as to cleanse the bowels 
thoroughly, had a very good eftect. Cool air, barley water, with vinegar or 
balm tea, and when the skin was dry with gi-eat restlessness, tejjid bathing of 
the whole body, was found useful: this practice was confined to tlie inflamma- 
tory stage of the disease; when the debilitated state canic on it was not advitin 



T36 OF THE MEASLES. 

When tlie pulse was quick, low, and irregiilar, in the seoond stage, with 
great debility, wine whey, or wine was useful^ laudanum also did good in the 
diarrhoea when combined with gentle astringents; Peruvian bark was given af- 
ter the fever had subsided and nothing but debiUty remained. 

Dr. Qiiier found blood-letting indispensable in the highly inflammatory dy- 
senteric form before described in p. 230; he bled as soon as the patient com- 
plained, as much as he would bear; before the inflammation of the throat ap- 
peared, a purge of sulphate of magnesia was given witli good effect; if tlie 
throat and ahmentary canal, however, had become inflamed, they coiUd not be 
borne; emollient decoctions were then used as the common drinks; spermaceti 
or gum tragacanth emulsions to reheve the cough, witli small doses of lauda- 
num at night, and lead-water, as a collyrium, were attended with benefit: 
Free bleechngs were often necessary before the height of the fever; the spasms 
of the stomach and bowels, with incessant pain, were relieved by bleeding and 
two or three grains of opium in the coiu-se of the day; chalk and armenian 
bole were also used to allay the irritation of the bowels; starch injections 
with laudanum were also useful. Purgatives after the disease of the stomach 
and bowels had fairly set in, sunk the patient too much to be borne; they were 
not even used till after tlie whole u-ritation had disappeared from the fauces 
and the scabs had fallen off*; then sweet oil, manna, or some gentle cathartic 
was useful. Bleeding was at that period hurtful. Opiates with emoUients and 
demidcents, and blisters to the thighs abated the cough; whilst the dysentery 
tenesmus and gripings were reheved by opiates and oily pui-ges: the purges 
were continued for some time, if fever, slight nausea, and tension of the belly 
returned with griping pains, which they did at the interval of some days, even 
after the convalescence liad been established.* C. 

* Quier's account of measles in Jaraaicaj Loud. 1778. 



( 227 ) 



^? 



CHAPTER 

OF THE SCARLET FEVEK. 



First Notices of the Disease. — Nosological Distinctions. — 2^6- 
scription of the different Varieties of Scarlatina. — Diagno- 
sis. — Prognosis. — Pathology. — Principles of Treatment. 
— NatxLre and Treatment of the Dropsy succeeding Scarla- 
tina. 

riRST NOTICES OF THE DISEASE. 

The scarlet fever is probably a disease of very modern origin. 
No mention of it is made by the ancient or Arabian authors, and 
the first time it is distinctly noticed is but little more than two 
hundred years ago. It has been suspected that the contagion 
came originally from Africa. Be this as it may, it first showed 
itself in a severe form in Spain in 1610, from whence it spread to 
Naples, where it raged epidemically in 1618. In 1689 the same 
disease made its appearance in London, and was described by Dr. 
Morton, though not with the accuracy of the first Spanish and 
Italian authors. In 1735 it broke out in North America, and 
spread gradually but slowly over that continent. One of the 
most curious circumstances in the history of the disease is the 
slowness of its difi'usion. 

NOSOLOGICAL DISTINCTIONS. 

When the scarlet fever first appeared in Europe, it was in a 
very malignant form; but between the years 1660 and 1670, a 
febrile complaint attended with scarlet eruption was observed by 
Sydenham in a degree so singularly mild, that nosologists have 
doubted its being really the same disease with that which had 
previously occurred. Dr. Cullen believed it was specifically 
difierent. Dr. Withering states, that in his early practice he 
considered scarlet fever and putrid sore throat distinct diseases, 
requiring distinct methods of treatment. More enlarged expe- 
rience however compelled him to renounce that opinion; and he 
says, that after paying the most assiduous attention to the subject, 
by observing the complaint in every difference of season, expo 
sure, age, and temperament, he was satisfied that they consti- 
tuted but one species of disease; — that they owe their existence 
to the same specific contagion; — >that the variations in their ap- 



238 OF THE SCARLET FEVER. 

pearance depend upon contingent circumstances, and their great- 
est diflercn 
small-pox. 



est differences not greater than those of the distinct and confluent 



VARIETIES. 

The scarlet fever attacks the skin, the tonsils, and the mucous 
memhrane in their neighbourhood. In mild cases there is eJ]lo- 
rescence, with little or no affection of the fauces. This constitutes 
the scarlatina simplex. In very severe cases there is extensive 
ulceration of the fauces, attended with typhoid fever, but with 
little or no effliorescence. This is the extreme grade of the dis- 
order, and is called cynanche, or scarlatina maligna. In the 
common or intermediate cases both structures are implicated, and 
the disease is then denominated scarlatina anginosa. 

1. The scarlatina simplex commences with slight febrile symp- 
toms. The eruption appears on the second day, first about the 
neck and face, in the form of innumerable red points, which in 
twenty-four hours or less cover the whole body. On the limbs, 
but especially about the fingers, there is a diffuse and continuous 
efflorescence, but on the trunk of the body the rash is distributed 
in irregular patches. The colour of the eruption is a bright scar- 
let, being always most distinct about the loins, and bondings of 
the joints. On the breast and extremities, in consequence of the 
great determination of blood to the miliary glands and papillce of 
the skin, the surface is often rough, and there is an appearance 
of papillai or even minute vesicles, as in miliary fever. This is 
very liable to happen when the patient is confined in a small room 
and loaded with blankets. The elflorescence spreads over the 
surface of the mouth and fauces; and the papillae of the tongue, 
which are always elongated, extend their scarlet points through 
a white fur, thus affording one of the simplest diagnostics of the 
disease. The face is often sensibly swelled about the third day. 
The febrile symptoms are in some cases very slight. At other 
times there is considerable heat of skin, restlessness, and frequen- 
cy of pulse. The eru})tion continues about three or four days, 
after which a desquamation of the cuticle takes place. 

Siuklcn swelling's of the lips and cyeruls, coming' on in the night and going 
oil" without any jjuin, and in one case, ending in su})j)uniti()n and death; tdso of 
the cheeks, and tliroat, have l)een observed l)y Dr. Kusli during the prevalence 
of scarlet fever: Tiie swelling occurs irregularly on certain ])arts of the hody; 
Hometimcs on the breast, and soniethnes on the limbs, and not upon the neck 
and face. C. 

2. In the more common form of the disease, the scarlatina 
aiiL^inusa, the precursory symptoms are more violent, and to- 
gether with the cutaneous efflorescence, an inflannnation of the 
fauces appears, going through its progress of increase and decline; 



OF THE SCARLET FEVER. 239 

along with it. Among the first S5^mptoms of this disease is an 
uneasiness in the throat. The voice is tliick, and deglutition 
diificult. The tonsils and fauces appear red and swelled, as in 
cynanche tonsillaris. For the most part this goes on to the for- 
mation of superficial ulcerations or specks. When these are nu- 
merous, they cause an unpleasant foetor, and the throat is much 
clogged up with a viscid phlegm. 

Weariness^ dejection, chills alternated with fever, and transitory fits of sick- 
ness, restlessness at night, introduce the disease: The cUfficulty of deg-lutition 
proceeds more from an inability of moving the muscles of the throat than from 
the pain produced by the attempt, or the straitness of the passage; the mus- 
cles about the neck and shoulders, indeed, seem affected from the first com- 
mencement of the fever with soreness and stiffness, and feel as if bound round 
with cords: The eruption is introduced by a hot and dry skin, and a pricking 
sensation of needles; all these symptoms increase, the skin becoming more af- 
fected, till it is of the color of a boiled lobster, and smooth, and without the 
slightest appearance of pimples or pustules: The eyes and nostrils are also red, 
and ill proportion as they are high coloured, so is the tendency to delirium.* 
The fever, which is often of alow type, Dr. Rush and Dr. Parry both state is 
sometimes inflammatory with cupped blood.j- Indeed Dr. PaiTy remarks 
that no case in a person coming from London to liath, even though very weak, 
was without inflammatory symptoms; they were always relieved by venesec- 
tion; the dropsy which followed was cured in the same way: I know it to be a 
truth, that without bleeding in inflammatory cases, this disease is likely to ter- 
minate in croup, and active inflammation of the lungs: ulcers in the trachea ap- 
pear from dissection to be a common symptom in all cases of scarlatina angi- 
nosa. C. 

In this more aggravated form of the disease the efflorescence 
seldom appears before the third day. It chiefly comes out in 
scattered patches, always very distinct about the elbows. Fre- 
quently too it vanishes, and re-appears partially, and at uncertain 
times. About the fourth or fifth day from its first appearance it 
is generally gone, and extensive exfoliation of the cuticle begins 
soon afterwards to take place, and continues for ten days or a 
fortnight. About the seventh day it is not uncommon to find 
the patients complaining of considerable pain in their hands. 

The nails and the skin from the tongue sometimes peel off about tlic same 
time; the desquamation generally begins with a perspiration; the eruption 
sometimes continues even to the tentli day. 

When the case is violent, the eruption appears on the second. Hang saw it 
on the first day; it has also been seen within twelve hours after the commence- 
ment of the disease: This happens mostly in children, who become delirious 
and die on the third day. It appears first about the face, spreading soon over 
tlie neck and breast, and at last over every part of the body: Sometimes it dis- 
appears upon the second day, or within twenty-four hours after its first appear- 
ance, and in those (more ]iarticularly in children) in wlvom the disease does 
not terminate suddenly by death. Withering states, that often the skin becomes 
dj-y and harsh, the pulse continues feeble and quick, the mouth parched, the 
eyes heavy and sunk, the tongue hard, dry, and dark brown, witli an tiAcrsion 

* Withering, 1779, p. 3,4, 5. 

t Parry. Postlmm. \^'orks, vol. i. [). 168. 



UO OF THE SCARLET FEVER. 

to all kinds of food, and great uneasiness upon the least motion; a discharg-e like 
mucus or pus, of an amber colour, runs in great quantities from the nose or 
ears; in these cases recovery is slow. This symptom is also noticed by Dr. 
Uush. 

Sometimes adults also die upon the fourth day, more particularly if a purging 
supervenes: the eyes look of an equable shining red, like those of a ferret, 
without great sensibility to light: by lifting the eyehd this symptom is discover- 
able even before it becomes general over the eye: Livid spots also sometimes 
occur about the elbows, breast, and knees; great difficulty of swallowing, and 
trismus, are among its uncommon symptoms; inflammation in the eustachian 
tube, pains and soreness in all the limbs also occur: Sometimes the pulse is hai-d 
so as to justify the opening of a vein, the blood being sizy, and the crassamen- 
tum firm; the latter appears upon a change of weather.* 

Dr. Rush has seen an eruption like the chicken pox attend the sore throat: 
other authors also mention it: the fever does not dechne with the swelling of the 
throat or the appearance of the eruption, except in the most favourable cases; swel- 
lings of the maxillary and parotids sometimes accompany it, are painfid on pres- 
sure, and by their protrusion aflect the breatliing; they end in abscesses on the sides 
of the neck under the ears: Sometimes the fever returns, particularly if the skin 
remain dry during the desquamation, and is followed by another eruption: a 
tlry skin is always a sign of a protracted disease: The swelhng of the parotids 
and running of the ears also portend the same thing;-|- they prevent as long as 
they continue, any moisture on the skin. C. 

The febrile symptoms in this form of scarlet fever are usually 
very sevcrCj and of a highly inflammatory character. The heat 
of skin is more intense in this than in any other fever of our cli- 
mate. The pulse generally averages 120. There is always much 
restlessness, languor, and oppression of the breathing. The 
countenance is expressive of very peculiar anxiety. The eyes 
are sufTused. Head-ache is often a very urgent symptom. The 
decline of the disorder is usually attended with marks of great 
debility; and not unfrequently permanent deafness is left by it. 

The pulse is often quick, small and feeble; obstinate dropsies, suppura- 
ting swellings about the neck, nose, and cars, leaving incurable ulcers, involv- 
ing the soft parts as well as the bones, also follow it; it affects also the mouth, 
lips, palate, the arms, and the anus: the trachea, tlie lungs, are also the scut of 
chronic diseases, resulting from it. Dr. Rush mentions a squeaking voice, re- 
sembling the croup, as !iccom]:)anying it: Epilepsy sometimes precedes and fol- 
lows the dropsical swellings: they arc said not to be fatal, but are generally 
o>ving to cokl, or some irregularity in diet. Sometimes tlie dropsy affects tlie 
brain, producing wakefulness, blindness, coma, expansion of the h-is; some- 
times it attacks the lungs, with symptoms of dropsy of the chest; tlie skin be- 
ing dry and harsh; the \irine of a deep l)rown colour, depositing a sediment of a 
mahogany colour, and in a powdery form. C. 

3. The third or maUgiiant form is that which the scarlet fe- 
ver assumed in London in 1745, and which is so accurately des- 
cribed by Dr. Fotlicrgill. It is ushered in by rigors, attended 
with giddiness, acute liead-ache, restlessness, faintncss, a sense of 
heat and soreness of the tliroat, vomiting or purging. An cfHo- 

• Withering, p. 8-17 
f Philip, p. 4:>-4. 



OF Tim SHAULKT FFATT?. ^11 

rescence appears at irrcgnlar periods from tlic second to the fourth 
day, but is seldom permanent. A remarkable tumefaction of tiie 
fingers sometimes takes place, which, with the erysipelatous 
tinge they soon acquire, is often of itself suflicient to character- 
ize the disease. In the throat appear dark sloughs surrounded by 
a livid base, and occasioning intolerable foetor. The parotid 
glands swell, and become painful to the touch. The mouth is 
encrusted with a black or brown fur, and a viscid phlegm clogs 
up the fauces, so as even to threaten suffocation. The inside of 
the nostrils appears of a deep red or livid colour, from which a 
corrosive sanies flows, excoriating the angles of the mouth and 
cheeks. These symptoms are often accompanied by severe di- 
arrhoea, with haimorrhages from the nose, mouth, and bowels. 
Those who escape these dangers, have afterwards to struggle 
through the extreme weakness left by the disease, and the diar- 
rhoea, or hectic, which often supervene. The accompanying fever 
is typhoid. The pulse is small, feeble, and irregular; and often, 
from the very commencement, there is delirium or coma. 

Sometimes the pulse is quick, hard and small; in others soft and full, with- 
out bein^ tense as in inflammator>' diseases:* The blood is fluid, and fresh, 
the ci-assamentum looser serum yellow and large in quantity: The thirst is less 
than is common in high fever. 

Sometimes tlie disease approaches without fever, the ulceration making gi-eat 
progress into the lungs and bowels; alternate chills and heats; sometimes 
only anxiety and general distress precede it, the person going about till 
at last he is obliged to lie up; lioarseness, cough, heaviness and oppression 
at the l)reast with constant sighing; the face and hands swelled and red; sick- 
ness at stomach, dejection of spirits, sudden weakness, faintness, the pulse 
with a quick, small, or a heavy, undose beat; the urine pale, thin, crude and 
watery; in small quantities and high coloured, or like turbid whey; with heavy, 
reddish or weeping eyes, the countenance full, flushed and bloated, though 
sometimes pale and sunken, occur as symptoms from the beginning: 

Previously to the sloughs, the fauces appear sliining, highly red, swelled or 
covered with'pale white patches, suiToundedby a livid or red colour, and follow- 
ed by the sloughs, as the author mentions: The tonsils and whole inside of the 
throat are swelled and inflamed, or a swelling suddenly appears in a neigh- 
bouring part, as beliind the ear, which subsides into tlie tliroat; these sjTnp- 
toms gi-adually become aggravated; the sloughs increase; vomiting, coma, 
and deUrium, in addition to the above, mentioned s^Tuptoms, appear; the 
tongue becomes covered with a thick, yellowish or brown coat, the breatli be- 
comes nauseous, the smell increasing hourly till at last it becomes intolerable: 
the symptoms gi-adually increase, the voice is hollow, and hoarse, with a rat- 
tling stertor, as if the patient was strangling: Those who recover about the 
third or fourth day spit up a great quantity of stinking putrid mucus, tinged 
with blood, livid and fcrtid; This discharge getting into the trachea or bowels 
produces inflammation, which is often fatal: Sometimes the scarlet eruption 
comes on before, and sometimes after the soreness of the throat: it is pailial or 
general, erysipelatous or pustular,. in different degrees; of a crimson colour, 
witli great swelling or inflammation of the skin, relieving the internal symp- 
toms at times, at others not atall;-{- Swelling, hvor, with an intolci-ablc stencli 
take place before death. 

* Med. Communicat. vol. ii. p. 371. 

I Huxham, vol. ii p. 27G ct scq. Lend. 1788. 

Vol. II.— 31 



242 OF TIIK SCAKLKT FEVEK. 

DIAGNOSIS. 

The only disease with which' scarlet fever is hable to be con- 
founded is measles. From this it is to be distinguished by the 
character of the eruptive fever, the colour of the eilloresccnce, 
and the affection of the fauces. 

In obedience to the g-cneral system of arrangement observed in this work, 
\vc state the diagnostic qualities of" the various grades of scarlatina considered 
with regard to other diseases, thotigh the diseases of the skin run into each 
other so insensibly, that we are disposed to adopt the old opinion of Sennertus, 
that they are all varieties of each other; yet as, in this book, the author has 
chosen to consider scarlatina and measles as separate affections, we shall, with- 
out going farther, regard them only ;is prominent points in the great surface of 
analogical phenomena, which embrace the whole riinge of diseases of the skin. 
The distinctions below, of course apply to the middle and more prevailing 
grades of these morbid states; out of this pale, they will be found to shade off 
into each other in an insensible manner. 

1. Character of the eruptive fever. The efflorescence of this disease ap- 
pears generally on the second day: In the measles, seldom till the fourth. In 
the scarlatina it is more full, spreads more and consists of innumerable points 
and specks under the cuticle intermixed with minute pimples, in some places 
forming continuous irregular patches, in others coalescing with a uniform flush 
over a considerable extent of surface.-]- 

In the measles, the rash is composed of circular dots partly distinct, partly 
set in small clusters or patches and a little elevated so as to give the sensation 
of roughness on passing the finger over them; " These patches are seldom 
confluent, but form a number of crescents with large intervening portions of 
cuticle which retain their usual appearance :" 

2. Colour of the efflorescence. The colour of the rash in the scarlet fever 
is like that of a boiled lobster shell; in the measles, of a dark reddish-brown 
like a raspberry; 

3. Affection of the fauces. In scarlatina, the cough is short, without ex- 
pectoration: In measles, it is obstin:ite, harsh, and attended with the discharge 
of a tough acrimonious phlegm, coming up in repeated efforts: 

4. Affection of the eyes. In scarhitina, the redness of the eyes is not at- 
tended with intolerance of light; tl»e cili;iry glands arc not affected; and though 
they appear watery and shining, they never overflow: 

In measles, the insensil)ility to light, and the inflammation of the eyes and 
eyelids is considerable: The eyes run tears, ami there is great cory/a, and 
sneezing: 

In tiie scarlatina, depression, anxiety and great weakness attend the fever; 
in the measles, inflammatory symptoms, except in the typhoid variety. t C. 

Where measles however occurs complicated with cynanche 
tonsillaris, as I have occasionally witnessed, the diagnosis may 
be difficult. 

The common inflammatory .sore throat (or cyn:inche tonsillaris) is distin- 
guished i)y its occurring in the hctilthy, plethoric, yo\mg and vigorous: for the 
weak, delicate and infirm suffer less from it, :ukI :ire al.so less ruibic to it: 
whereas the typhous form (<)rcyn:uu:he n):iligiia) generally attacks the l:iltcr: 
and this last forn» is j)articul:uly distinguisheil by sickness, :icutc' p:iin in the 
top ;u»d back parts of the head conjing on in a few liours: and when the rcd- 



t Thomas p '-<»■"*• ' Thoin 



UV TIIK SCAUI.TVI F1',VF,4{. Uo 

nessandslcMighing- of the fuiiccB appear, the typhous form is evident and wcU 
marked i* The redness of the face, neck and hands also distinCTiishes the dis- 
ease from cynanche tonsillaris, which is a local inflummatory affection; cyn:ui- 
che malig-na on the contrary is a disease of the wiiole system, affecting the 
throat more particidarly.f 

The dehrium, also, wiiich attends the scarlatina maligna, the ulceration of 
the throat, the hemorrhages, the sloughs, also sufficiently distinguish \i.i 
Cynanche tonsillaris ends in suppuration or schirrus. 

The hlisters, the slow spreading and limited redness of the skin distinguisJi 
it sufficiently from erysipelas. Petechiae differ from scarlatina in being dit 
tinct and regular in their form, and in occupying mostly, the neck, back, 
shoulders, and loins. The blotches in scarlatina are generally broad, or one 
great Burfacc of redness spreads over the whole body. (J • 

PROGNOSIS. 

The prognosis in scarlet fever when it assumes cither of the lat- 
ter forms, should always be guarded. It varies of course with 
the degree of violence of the febrile and local symptoms. The 
malignant scarlet fever is a disease of the utmost danger. Some 
die as early as the third or fourth day. Some linger on till the 
second or even the third week; but generally it may be said that 
the patient is safe if he passes the ninth day. The recession of 
the eruption is always an unfavorable symptom; but the whole 
history of scarlet fever proves 4hat it is more a disease of mucous 
membrane than of the skin, and the danger is therefore to be es- 
timated by the extent to which that structure is implicated. 

The signs of a favorable termination are lateritious urine, the abatement of 
the heat and fiery redness of the skin, which becomes of a brown colour^ the 
desquamation of the cuticle and the subsidence of the tumefaction: also reces- 
sion of the swellings, greater slowness of the pulse; the falling off of the 
sloughs; filling up of the ulcerations, easy sleep, and return of appetite. 
Great , increase of fever and thirst, foetid breath, the rash interspersed with livid 
spots, low irregular pidse, delirium, prostration, bleeding from the mouth and 
nose; severe diarrhcEa about the sixth day; anasarca, atropliy, are unfavoura 
hie: This last affection often destroys in a few weeks. The fauces becoming 
dry, livid and glossy, of a brown or purple colour without swelhng; ash colour- 
ed or brown specks soon ulcerating-; the external tumour growing large, pro- 
fuse sweats, great debility, petecliix, delirium, coma, involuntary evacuation of 
the fxccs, cold extremities, are also unfavorable in the highest degree. Some- 
times inflammation of the trachea closes up the glottis and destroys life. C 

Swelling of the parotid gland sometimes accompanies the period 
of convalescence, and proves both painful and tedious. 

PATIIOLOGY. 

Scarlet fever arises from a specific contagion, which has a la- 
tent period of from four to five days. There is a peculiar suscep- 
tibility of it in infancy and youth. Sir (jili)ert Blanc observes, 
that he never saw a j)ersoii turned of forty affected by it. It is 



FoUicrgill, p JJi t J''i^^' I'- --^- * Ibid J27. 



244 OF THE SCAULKT FEVEK. 

not however in this respect upon the footing of small-pox and 
measles; — a disease, that is to say, which almost every one pas- 
ses through; for many individuals resist it, although exposed to 
the full influence of the contagion. But though specific contagion 
is the generally acknowledged, and certainly the most prevalent 
source of scarlatina, there is yet abundant evidence that fever, 
attended with scarlet eruption, and possessing all the other char- 
acters of this disease, does occasionally -arise from exposure to 
cold. 

A great controversy has taken place upon the question of se- 
condary attacks of scarlet fever. Dr. Withering and Dr. Willan 
never witnessed a recurrence of the disease. It has been satis- 
factorily shown however that this does occur, and second attacks 
have often proved severe.^ Scarlet fever is commonly said to 
prevail chiefly in autumn, but it has been observed in all seasons 
of the year.t The form which it assumes in particular cases is 
partly to be attributed to the character of the epidemic, partly to 
external circumstances, and in part also to the constitution of the 
individual afiected. It has been made a question, to what causes 
we are to ascribe the malignity of a particular epidemic. Season 
is said to have some influence, the inflammatory form of scarlet 
fever appearing in spring and sumrtier, and the typhoid in autumn 
and winter; but no stress can be laid on this, for the complaint 
has been observed at the same time in all its forms, in individuals 
of the same family. Upon the whole we must acknowledge, that 
the circumstances which determine the severity of this or any 
other febrile disease have never been satisfactorily explained, and 
perhaps they are really inscrutable. It is not accurately known at 
what period a convalescent ceases to be capable of communicating 
the infection. The power of infecting appears to continue a 
very considerable time; certainly a fortnight from the decline of 
the efflorescence, and probably as long as any desquamation of 
the cuticle takes place. 

TREATMENT. 

Nothing need be said regarding the treatment of the scarlatina 
simplex; but the principles which are to guide us, when the 
disease occurs in either of its two severer forms, require conside- 
rable attention. 



* Persons who take tlic scarlet, fever and eruption witliout the sore throat, 
arc liable on its appearance ag-ain to have the sore throat without tlie fever ami 
eruption; and those who have the sore tln-oat witliout the fever and eni])tion, 
are liable to take the fever and eruption without the sore throat: \u tliis piu'tic- 
ular it resembles the snnall-])ox and measles. G. 

f The disease is most likely to apj)ear in the end of summer, thoug-h it may 
arise at all seas(ms: A severe frost they say checks it, and afterwards it appears 
with more violence: it j^enerally disappears in the spring^, though it luis contin- 
ued for several years unchecked by any chang"e of weather. C. 



OF THE SCAULRT FEVER. 2A-S 

They have given rise to much controversy, and were certainly 
not satisfactorily explained till within these few years. The 
treatment of scarlet fever is to be regulated in the first place by 
the character of the accompanying fever. Where inflammatory 
symptoms prevail, they are to be moderated; where the typhoid 
disposition is manifest, the system is to be supported. To a cer- 
tain extent, indeed, it must be allowed that the character of the 
fever is under the control of the practitioner, who by vigorous 
treatment at the onset, may prevent many symptoms of malig- 
nancy or putrescency ; but this principle is only of partial appli- 
cation, for he has no control over the character of the epidemic. 
The other extreme, however, is equally to be avoided, which is 
regulating altogether the early treatment by the consideration of 
the possible symptoms which may arise. In a disease assuming 
such different forms as scarlet fever, the existing symptoms must 
be the guide of practice. 

To allay the high vascular and especially cutaneous excitement 
which prevails in the early stage of scarlatina anginosa, affords us 
a second general principle of treatment. At one time it was sup- 
posed that blood-letting was necessary; but experience has proved, 
that in the cold affusion w^e possess a means of controlling this 
state of disease, safer, and for the most part, (though certainly 
not always) equally effectual. We are indebted to Dr. Currie of 
Liverpool for this improvement in practice. The great heat of 
skin renders the cold affusion grateful to the patient. The disor- 
der prevails chiefly among children, in whom it can be applied 
with facility. In common cases of scarlatina there is not that 
degree of febrile weakness which the fatigue of a cold affusion 
would augment. There is no tendency to affection of the chest, 
as in measles, which the application of cold to the surface might 
aggravate. An ulcerated state of the throat forms no objection 
to its use. On the contrary, the cold affusion frequently checks 
this symptom in the most remarkable manner. The repetition 
of the remedy at intervals, proportioned to the urgency of the 
symptoms, is indispensable; it may be safely applied whenever 
the skin is hot and dry. It cools the skin, abates thirst, dimin- 
ishes the frequency of the pulse, the head-ache, and the languor, 
and disposes to sleep. 

Dr. CiiiTie advises that the bowels should be freely opened by laxatives, of 
which the best is the sub muriate of mercury; with cold water and lemonade, 
and water w^ith muriatic or oxy-muriatic acid, as drinks, during- the use of the 
cold affusion; He also gave a solution of tartrite of antimony, and he states that 
out of 150 cases, in v/hich he used the practice, his success was nearly invaria- 
ble. Vinegar and water applied to the body by a sponge may be substituted 
when the fever has abated, as a means of lessening it to a greater degi-ee. It 
should never be applied when it produces chilliness, and when prejudice pre- 
vents its use it may be administered tepid. The great heat and dryness of the 
skin, the tension of the pulse, the patient still possessing considerable strength 
should be the indications for using it; avoiding it, when the pulse is low, small 



346 OF TIIK SCAKLET FKVEIJ. 

and irregular. Drs. Mossman, Iticd, Thomas, Diitcman and Stranger,* as well 
as Dr. Currie, give Balisfactory testimony of the value of tliis plan. 

Sometimes however the disease is completely typhous from the first; the 
seizure is then sudden, with a sinking- pain at tlie stomach; an extreme pros- 
tration of strength; an irregidar feeble pulse, with stupor, delirium, convul- 
sions or sleepiness which continues till death: vomiting-, purging, profuse 
sweats, bloatedness of the habit, swelling of the throat as if from the mumps; 
cadaverous odour, with dissolved blood, and every mark of debility; in these 
cases, cold affusion or any other active depleting means would be fiitnl.f They 
nre likely to occur in northern latitudes, and where the system has been debili- 
tated by previous illness. 

The typhous symptoms of scarlatina seem to be often produced by the abs- 
traction of blood, filling the vessels of the surface, and also from the inflam- 
mation of the skin, which, as in extensive burns, depresses the system; it will 
therefore require great judgment in the practitioner to determine when stimu- 
lants lire to be used; Dr. Withering, though the pulse was weak and feeble, 
found tiiem hurtful, except in their mildest forms, as camphor, &,c. The truth 
can be discovered by feeling our way cautiously and taking the proper precau- 
tions not to give them in too large doses; if they excite heat of skin, increase 
of thirst, delirium, &c., they must be avoided: Withering found the bark ex- 
tremely useful; in prescribing it, however, the greatest circumspection is also 
requisite. The livid spots which appear upon the skin which look so much like 
gangrene, often proceed from the rupture of a blood-vessel; the sloughs in the 
throat arise always from inflammation: they are, therefore, to bcttreated in the 
lirst stages by tlie antiphlogistic plan above advised; if the typhous state has 
set in, bark does wonders. Experience can only determine when this is the 
case: If this or any other stimulant are received with dislike, produce heat, 
thirst, restlessness, increase the delirium or distress in any shape, they must be 
uvoided: On the contrary, if tlie patient feels better, the mind is clearer, tlie 
fever cooler, there is no doubt that they are useful. Oppression, anxiety and 
great debility, with a pulse so quick and frequent, that it cannot be counted for 
a quarter of a minute together, sliew that these stimulants will agree with the 
system, and that blisters are useful :t In general, however, the latter remedy 
3s not advisable at any season. If tlie brain was much affected with delirium, 
J^r. Withering found that they did no good; on the contrary, harm. When the 
disease became more typhous in its character, towards the autumn, a blister 
round the throat was useful, but less so in inflammatory diseases, and this can 
he well understood from the excessive disposition to inflammation of the skin 
which characterizes this disease. When the fever ceases and the debility is 
great, nothing gives so much relief as bhstcrs.^ C. 

Blood-letting is sometimes indispensable, especially when the 
disease attacks adults of full habit of body. An apprehension 
has been entertained regarding the debilitating effects of this 
practice in scarlet fever, which may safely be disrcgarde<l. Head- 
ache and general oppression are the symptoms which most ur- 
gently call for its adoption. Leeches to the temples are ooca- 
fiionally sufficient. These may also be ajjplied with great ad- 
vantage to the throat, when the swelling of the tonsils is vcr}- 



• Dune. Annuls, 1799, XII. Med. 'and Tlivb .Journal, vol \\. '27, (iuotcd'l>y 
Dr. Thomas, ]>. 272. 

I New PLngJund .lournal, Jan. 1825. 
i Withering, p. 91. 
r Ibid. p. 97 



OF THE SCAia.ET FE^KU '^T 

^rcat. Thoy commonly bleed freely in this disease, in consc- 
quenco of the excited state of the cuticular circulation. 

With regard totlic use of blood-letting', in cases of high delirium and com:i, 
Navier found it to be particularly valuable when the pulse was hard, and tlui 
I)utient robust^ the juijular or temporal artery has been advised'to be opened 
in this case, a proof of the variable character of the disease,* and that it i^ 
not always typhous. Dr. Withering-, however, found it seldom practicable from 
the lowness of the pulse; he states, as tlie scarlet colour of the skin declined, 
tlie fauces became more red, the symptoms pneumonic, and the pulse harder, 
the patient bore bleeding better; still not so well as in ordinary inflammations. 

Dr. Mortoii has also advised bleeding- from the arm, and when the head i^ 
much affected from the jugular vein; this may apply to the inflammatory cases, 
and when the hardness of the pulse, the excessive heat of the skin prove that 
this evacuation is imperiously demanded; these cases however rarely occur. 
Dut when the type is malig-nant, and followed soon by a sudden prostration, 
g-eneral blectling- will always be diingerous, and if practised it should be in li- 
mited qiiantity, and with the greatest caution. It is true that Dr. Armstrong- 
advises depletion of a decided character early in this disease; and renounces 
entirely tlie stimulating plan formerly practised: at its fii*st onset this may ha 
proper; but we think that the bleeding had better be tiiken from the head amt 
neck, the parts likely to suffer from the febrile nisus, and thus its strength 
may be overcome, without debilitating the whole system by a copious general 
evacuation, which will affect little the parts most likely to suftcr, and if the 
diathesis is typhous, there will be less danger of incurable prostration. Dr. 
Armstrong advises during the paroxysm of excitement, if the cold affusion 
does not succeed in reducing it sufficiently, that a vein should be opened, and 
the operation repeated in an hour or two: By lessening the action he thinks 
it prevents the typhous symptoms which he supposes result from the recess of 
the fever. The head must be kept cool by towels wet with cold water, and 
be elevated to favour the descent of the blood; The bowels should then be 
freely purged by calomel and jalap, assisted by the sulphate of magnesia, and 
this plan followed up throughout the disease. If it is not carried into effect, in 
thirty hours after the attack, it is without avail. C. 

Emetics have been strongly recommended throughout the 
whole course of scarlet fever; but they are not advisable, except 
at the very onset of the disease. 

Ipecacuanha, or tartar emetic will be proper for this purpose, as they arc 
uscfid not only in clearing the throat, of any improper secretions that may be 
lodged there; but also in preventing diarrhoea from the acrid sordes accumu- 
lated in the stomach. 

They were given in union with calomel by Dr. Rush in 1783-4 with goo<l 
effect; opium sometimes was necessary to be added to restrain their pui-gativc 
effects, which often cut short the disease by suddenly putting a stop to the fe,- 
ver. 

Withering states, that he often cut short the disease by giving an emetic 
early; and if taken later, it always relieved the anxiety, faintness and delirium; 
the tumefaction of the throat and the peripneumonic symptoms were also 
amended by it in the greatest degree; the vomit, (tartar emetic and ipecacu- 
anh:x,) should be active and powerful, and repeated once in forty-eight hours; 
in the worst cases once in twenty-four hours. 

U. T{ad. Ipecac, ^j. Tartrit. antimon.gr. i. m.ft. pulv., for a grown person: or the 
following mixture maybe given, H. Tart, antim. gr. iii. Vhi. Ipecac. ,^vi. Cret, 

* Navier de lieb. Commentar. p. 1. v. t. p. 340, 



248 OF THE SCARLET FEVER. 

ppt. gli. Aq. fontan. §vi. syrup 533. m. Take a table-spoonful every half 
hour till it vomits, for an adult, and lessen it in proportion as the person is young- 
er. In the typhous form they are pernicious. 

Moderate purging is greatly to be preferred, and yet a preju- 
dice against it was long entertained, probably in consequence of 
observing the danger of supervening diarrhoea. This symptom is 
however often prevented by laxatives, and it is perhaps occa- 
sionally dependent upon inflammatory action of the mucous 
membrane of the bowels. 

For tliis piu-pose, rhubarb and soda in equal parts given to a cliild of eight 
years, three grains every two hours till it operates moderately; or calomel and 
rhubarb of each three grains at the same interval; or manna with tartar emetic 
in a solution will be proper: If there be costiveness, as the disease advances, 
glysters will be useful and the repetition of the purgative, which however must 
be moderated as symptoms of typhus appear.* 

Dr. Hamilton, who attributes great virtues to purgatives, thinks that full and 
complete evacuation of the bowels is extremely necessary in this disease; and 
that its treatment principally depends upon it.f The use of purgatives how- 
ever is only proper when the disease has an inflammatory tendency, and tlien 
they should be mild; they are said to remove the diari'hoea very successfully, 
and to deplete as well as blood-letting; Dr. Willan recommends calomel and 
antimonial powder in combination; Dr. Binns also testifies in favoui' of tlieir 
use; of thi-ee hundred patients, treated principally by this means, none died; 
it must, however, be recollected, tliat in typhous cases cases the residt will be 
dangerous. Indeed when there is a disposition to typhus, purgatives must be 
altogether avoided, as they are often followed by death in twenty-four hours; 
so sudden is the reduction of the system;^ Dr. Withering quotes Sauvages, as 
witnessing the same results. We had better, in tiiis last case, as a general rule, 
depend upon enemas: and if depletion is thought advisable, diuretics will be 
found to be the best plan. Dr. Withering, in cases where the pulse was weak 
and feelilc, speaks highly of their value : He gave in the drink as much as two 
drachms of salt of tartar every twenty-foui* hours, with decided benefit. Ve- 
getable acids, neutnd salts, and the squills from their efl^ect upon the stomach, 
or their being disagi'ceable, could not be given. C. 

Gargles of infusum rosae are useful at an early stage to wash 
away the vitiated mucus; when the sloughs are separating, bar- 
ley water is preferable. In severe cases a blister may be applied 
to the throat. 

In the malignant form of scarlet fever, treatment of any kind 
is of course less eflicacious; but several of the measures already 
recommended may be had recourse to with a prospect of suc- 
cess. 

In general, as we ol)Scrved before, blisters will be found from their stimula- 
ting effects not to be useful, where the inflamniatory tendency is considera- 
ble; :ii\(l in the simj^le form, rubefacients or poultices will be sufficient; Drs. 
VVilUui, Rush, and otliers, however, have stated, that they have seen benefit 
from blisters. 'I'he gargles should be applied by injecting the fluid Into the 
throat, and not by holding the head back, and moving the muscles of the fau- 
ces, as it will increase the inflammation: barley water ;icidulated with the nitric 
uv mm-iatic :icids; the tincture of bark, with the tincture of roses and water 



Ibid. t VVithenny'. p. 81. 



OF THE SCARLET FEVEIJ. UO 

are good gargles; Camphorated spirits of wine, honey and water injected into 
the throat, arrest the disposition to form sk)ughs, when the case is typhous: 
The infusion of capsicum, and the fumes of vincg'ar us hot as the patient can 
bear it, will be useful. 

It is necessary to ascertain w^ith precision the exact type and force of the 
symptoms and the remedies which are likely to combat it with success. 
When the disease is of an eminently typhous character, evacuants as in that 
observed by Fothergill, v. s. whether general or local, purges and sudorifics 
are all pernicious. They increase the delirium, difficulty of breathing and rest- 
lessness; The sloughs in the throat grow larger and blacker; cold sweats, quick 
pulse, stupor and death are uniformly the consequence of their use. Tlic de- 
licate, phlegmatic and debilitated by previous ill health, the indolent, the aged 
particularly bear evacuants badly in the typhous form. 

Frequently lying in bed in this form alone is sufficient to arrest it; exercise* 
increases the fever, and purging gives strength to it. C. 

An emetic at the commencement of the disease has often pro- 
ved of great service, and in some cases appears to have complete- 
ly broken its force. 

In the typhous form, the free use of boncset (cupatorium perfoliatum) tea, 
or that of chamomile after a dose of ipecacuanha, will be eminently servicea- 
ble; if given immediately on the onset of the disease. 

Stimulant gargleS, as of port wine, or of decoction of bark 
with tincture of myrrh, are of considerable use. The bowels 
should be cleared by gentle doses of castor oil, but severe purging 
is dangerous. 

These remedies arc peculiarly useful, from the necessity of discharging 
"the foetid ichorous matter which flows from tlie ulcers in the fauces, and which 
produces the dian'hoea, excoriations, hemorrhages, &c.; for it is observed when 
there is a free discharge from the mouth these symptoms are mitigated: as 
also the excessive sickness, faintness wliichattcnds the typhous form.* Calo- 
mel is praised as a valuable purgative, as it vomits gently which sometimes has 
a good effect. Sage, chamomile or rose leaf tea, made pleasant with the oxy • 
muriatic, mm*iatic acid or vinegar and honey are proper gargles. If tlie sloughs 
are large, tinctui-e of myrrh, with decoction of l)ark, or with honey and vine- 
gar, are advised. These gargles may be injected into the tlu'oat, before eating 
or taking any medicine; the acrid sanies is thus washed away; and the diarr- 
hoea, &c. the result of it is prevented.f If the sloughs separate slowly tliey 
may be touched with burnt alum and a probe; If on the removal of tlic escnrs, 
a bleeding should take place from a small artery, the application of a solution 
of alum, of blue vitriol, or of vinegar ]:)y tents, or by throwing- the steam into 
the throat, and nostrils, and keeping the head raised and cool, succeed.* C 

Draughts with camphor, serpentaria, and ellier, may be given 
at first every four hours; but as the disease advances, it becomes 
necessary to support the patient with decoction of bark and acids, 
wine, opium and aromatics. In the severe epidemic which pre- 
vailed in the West Indies in 1787, capsicum taken internally, 
and employed as a gargle, proved very serviceable. The cau- 
tions however formerly laid down, when explaining tlie treatment 



* Fothergill, p. 242. \ Ibid, p 214. ; Ibid. p. 219. 
Vol. it.— 32 



250 . C»F THE SCAULET FEVER. 

of typhus, apply here. Symptoms must be watched, nor must 
Ionics he given upon the mere theory of their necessity. 

In the cpklcmic alluded to the diseusc uppronchcd often without fever, the 
ulceration inakinf;* rapid j)ro};Te.s3 at the same time: It appeared to be in some 
measure local: The red ])(pper had, therefore, more effect: the pulse was 
weak, without being; diminished in force: The receipt for preparing- the g-arglc 
is as follows; "Take two table-spoonfuls of small red pep])er and two tea- 
spoonfvds of fine salt, and beat them into a paste, and then add to them half .•* 
pint of boilinj^- water; strain oH" the licjuor wiien cold and add to it half a 
pint of very sharj) vineg-ar; let a ta])le-spoonfid of this liquor be taken every 
lialf hour, as a dose for an adult; diminishing- it in proportion for children."* 
This remedy divested the disease of its malig'nity, and cured almost all that 
took it: it is a stinudus of p^reat power and would answer well in cases of com- 
mon t} phus. Sonietimes it was g-iven in much smaller doses: its first eflect is 
to excite a kind of reaction in the stomach and ccsophagus, attended with great 
lieat in these ])arts, and still g-reater in the mouth and fauces; which gTadu:dly 
subsided and left a gvncral g-low over the whole bod}', thoug'h it excites the 
pidse but little: In some other epidemic sore throats, however, this])ractice w:is 
not attended with the same hap])y results: it dej)ends verv nuich upon the 
fever; if typlioid, of course it must be hurtful, and more cooling- plans must 
then be used. 

A saline mixture, composed of salt of tartar ^ii, lemon juice half an o/., and 
six oz. of water, or nitre 10 j^rs. every hour with one-eig-hth of a grain ever} two 
liours, if the fever runs hig-h, in the beginning- will be advisable; if the typhous 
disposition, however, shoulil be more decided, then camphor, wine whe} , or 
volatile alkali, or ojjium and camphor united may be ^iven every thinl hour; 
the warm b;ith will also be- found useful: Tlu-\ rtlievc successfully the fainting- 
and excessivi; weiikntss which attend the t\ plious.fonn: Wine may be also 
g-iven with balm, mint, or sag-e tea. 'I'he renuxlies should be directed to procure 
g-eneral, equable sweats; for this ])urpose, the lluxham's tincture of bark, will 
be found hig-ldy useful, with tlie wine whey, &.c. I luxham states that these 
sweats were always critical, when they came on about the third d;iy; The elixir 
vitriol 10 droi)s thrice a day with tlu- tincture of bark in claret or jiort wine 
and water, will be foui\d to be valuable. In the low typhous form blisters to 
the neck from the car to the clavicle are highly useful. ' vScarifications and 
removal of the sloug-hs by ])robes are improper, as they are followed by deej)er 
cscars below theni; It has even produced ileath, from tlie inflannnation the re- 
sult of the violence. 

The oxygenated muriatic acid, g'iven in Colombo tea, or in the infusion of 
hark, makes a pleasant and useful tonic; It must be g-iven from a tea-cup, not 
from a spoon, as the acid acts r;ipidly on silver, and produces a poisonous coni- 
pound. The plans generally adviseil under the head of typhus will be jn-oper 
here. 

The powderof contniverva, with (•b:dk, nutmeg- or cinnamon is calculated to 
stop diarrluL-:i, and promote pers])ir;ition; The aroniiitic electuary — the aromatic 
powder and si)iritus menth. pi[)eritidis were used by I'othcrg-ill in the low 
form. 

In the diarrlura, he found that these .stimulating remedies abated it; and if 
they did not suci-eed, he used after every stool astring-ents and anodynes in pro- 
portion to the exig-i-ncy of the case: In tlu' disease described by him, the diar- 
huca mostly ceased after the vomiting- in less than twelve hours after the attack; 
if it did not, the above means wei-e used to arrest it.-f 

Sonu-times the appearance of the diarrhu-a causes the cfllorescencc- sudden 
ly to disappear, with faint ne.ss and insensibility: The use of cordials and as- 

• Med. Commen. vol. ii. p. ;>72. 
I rotherivill, p. 'J.*?.*. 



()!• rut sc/VKLLr rEvi.u. ?.si 

trinpcnts then produces the eruption and arrests the diarrlura. This praclitr 
appHcs \vc believe to all typhous forms of disease, even to dysentery; cxeesji 
of purg-iiif;- debilitates, and must be stopped, otheruise the jmtieut succumbs. 
The aromatic electuary ,^ss, or the simple powder of coutruyervu in the suujc 
quantity, arc useful stinudants. 

In the tendency to suppression of urine, with g-reat tension and tumor of the 
belly common in this disease, emollient fomenUitions with chamomile flowers 
or other bitter herbs, and injections of salt and water, will be found to g-ive 
great ease by the dischart^e of winil; j^entle doses of rhubarb towards the lifth 
or sixth day, manna or the lci\itive electuary, followed by the bark, have also an 
excellent eflect: Calomel also is useful.* C. 

The convalescence from this disease is always v~€Ty tedious, 
but may sometimes be sliortencd by a jiulicious administration of 
bitters and cordials. At the same time it should be observed, 
that an excited and feverish state of the system frequently ac- 
companies the process of desquamation, recpiiring the long con- 
tinued use oi saline as well as of active apcrlerit medicines.. 

Shg-ht fevers, like hectic, night sweats, want of appetite, lowncss of spirits 
often follow scarlatina: Fresh air, with g-cntlc exercise, animal food, as mut- 
ton, fowls and beef, will be found to be necessary restoratives. In Europe ass's 
milk was formerly much advised for it. 

I have delayed to this period, all mention of a very remarka- 
ble phenomenon in the history of scarlet fever; — I mean the 
dropsy, which frequently succeeds it.t It generally takes the 
form of anasarca, but ascites has also been noticed. It as often 
succeeds the inildest as the severest cases. It occurs, on an aver- 
age, upon the twenty-second day from, the decline of the erup- 
tion, seldom earlier than thi sixteenth, or later than the twenty- 
fifth. It is preceded for several days by languor, costiveness, and 
sickness. These symptoms frequently continue, accompanying 
a quick pulse. Tlie urine is scanty, and often coagulates on 
heating. This species of dropsy sometimes proves dangerous 
from the occurrence of coma, but more commonly from thoracic 
symptoms indicating effusion in the chest. 

In speculating on tiic nature of this affection, Dr. Wells de- 
cidedly inclines to the idea of its being inllammatory, and in this 
he is supported by the opinions of later ])athologists. He argues 
that it is not owing to debility, for it often attacks those who arc 
strong, and passes by those who are weak; its occurrence is con- 
fmed to a particular period, though great weakness may exist 
before and after; and lastly, it is often attended with a white 
tongue and a bounding pulse. Ikit it must be admitted tliat its 



• Tluxham, p. 293. ct scq. 1788. 

I The reader will find a classical paj)cr on this subjcrf, from the pen of the 
late Dr. Wells, in the Transactions of a Society for the Improvement of 
Med. and Chir. Knowledg-c, vol. iii. pag-e 167. 



:J6J nl IJli: SCAKLI.l l KVEK. 

precise causes have never been clearly explained. The common me- 
thod of treating; this Ibrm of dropsy is by purging, squills, and 
digitahs. Some cases have lately been published pointing out the 
eflicacy of bleeding. I have .met with several cases, however, 
which appeared to indicate the proj)ricty of bleeding and purg- 
ing, but which resisted both, and ultimately yielded to bark and 
aromatic confection. 

The pulse, lieat of skin, thirst, &c. will determine tlic propriety of tlicsc 
plans; un enietie will be found useful, lis well us the other depletmg measures 
advised under the head of the febrile state. 

When there is g-reat debility, eomatose or peripncumonic symptoms, large 
and repeated blisters have been found advisable : ^Vithering• recommends, more 
particularly, as diuretics, dilute solutions of salt of tiu-tar, selt/er water, and 
squills, and when a free evacuation of urine is produced, tonics, g-entle exer- 
cise, hig-h seasoned food, wine, and flannel next the skin.* Ur. Underwood 
thinks that this afleclion arises from the too early and free administration of 
bark and wine in the milder scarlatina; it then occurs eiu'ly on tlie disapi)ear- 
ance of the eruption: hectic, u g-eneral soreness, with a great loss of strength 
also supervene. 

iCy in Uiis case, the pulse be not full, he advises light cordials, soft demul- 
cents, a light nourishing drink, obviating costiveness; lUso removal to tlic 
country. 

With regard to the prevention of this disease it Is satisfactorily proved, that 
by the conlinement of the sick to a separate apartment, by ventilation, and 
frequent change of bed and body linen, and syringing the throat, idso frequent 
washing of the handsof the attendants, perfect security will be ensured to the 
rest of the family: Thirty-seven boys in a boarding school in England were 
preserved perfectly l)y tliis means by Dr. llaygarth: The same practice pre- 
served a school of young ladies at Hath; though the attendants, who were ciu*e- 
ful to wash their hands, cild not change their ciotlus: The ml:isinata therefore 
do not adhere to the clothes. Conhnement of tlie sick to a se])arate room in the 
house, with the above i)recautions w ill be sulHcient to prevent the spread of 
the disease :-j- The ujjper story of the house might be devoted to this jjurpose, 
and by separating the sick, it may tluis l)c entirely kept under: To assist in 
this object, fumigations witli nuuiganesc, sulphuric acid, and s:dt as advised 
under the head of typhus; the use of the warm biitii for the purpose of clean- 
liness, also frc([uent changes of linen; the colil l)ath, b:u-k tmd wine, a gener- 
ous diet, free exercise in the open :iir, a ([uiet sUitc of niiud and airy ventihited 
apartments will be useful auxiliaries: Dr. 8inis found rhubarb in small doses a 
good preventive. 

In tJermany, the use of the belladonna has been proposed for the s:mic 
T)uri)Ose. Its author is ! lahneman of Leipsic; 15ernilt of Custrin states that out 
of one hundred and ninety-fue cases of cliildren umler fourteen, who took the 
belhidonna, and were freely exposed to the contagion, fourteen only w ere in- 
fected; ami that when he afterwards used a stronger preparation of that ili-ug, 
every one escaped: all tiiose exposed in fimilies, who had the scarlatin:i, ami 
who did not take the medicini>, took the disease, w hllst those wlio diil, eseaj)ed. 
Other strong testimonies are given in its favour: Korefl" of Berlin states, that 
if the bell:ul<)nn;i be t:iki.'n in proper doses for eiglit or nine d:\ys l)efore ex])o- 
aure, the jjcrsons t;iking it are safi*. The (juantities given ;ire very small: 
Three grains of the extract are dissolved in :u\ o/. of cinnamon water, and of 
this two or three drops are given to a ehiUl under twelve months, and one 
drop more for every year above tluit. In genend no eflect is ])rodueed by it: 
Sometimes however it produces an eruption like that of scarlatina: It renders 
the attack more mild, if it does not prevent the disease; and if t:iken lour or 
five days l>eforc exposure the ilisease never proves fatal. > C. 



• Withering, p. V\). \ Thom;i.s. 

I Ell. Med. ami Suik- Jour. Jan. IH.W 



( 2o3 ) 



CHAPTER VI. 

Hi: MINOU EXANTHEMATA. 



Herpes. — Herpes on the Prepuce. — Urticaria, or Nettle-rash. 
Lichen. — Roseola. — Pemphigus and Pompholyx. — Erythe- 
ma. — Framhoisia, or the Yaivs. — Its Symptoms a fid Pro- 
gress. — Peculiarities in the Contagion of this Disease. — 
Principles of its Treatment. 

In the present chapter I propose to treat of those lesser fehrile 
eruptions, which do not, under any circumstances, go to the ex- 
tent of affecting life, and are chiefly interesting with reference 
to diagnosis. They are herpes, urticaria, lichen, roseola, ery- 
thema, and framboesia. 

HERPES. 

1. Of all the lighter varieties of cutaneous eruption complicated 
with fever, herpes is that which is most distinctly entitled to the 
character of an exanthema. The term herpes is appropriated 
to a vesicular disease, preceded by febrile languor, and other 
marks of constitutional disturbance. The vesicles pass through 
a regular course of increase, maturation, and decline, terminat- 
ing in most cases, in about a fortnight or three weeks. Herpetic 
vesicles are distinguished by their occurring in distinct but irre- 
gular clusters, appearing in quick succession, being set near to- 
gether, and upon an inflamed base, which extends some way be- 
yond the margin of each cluster. 

To be more particular — its symptoms arc, according- to Ratcman, a sense of 
licat, pains shooting throug-li the chest or epigastric region, w ith fever for three 
or four clays, followed by patches of pimples appearing on the breast and 
shoulders, with a circumscribed efflorescence round them, speedily jjutling- on 
a vesicvdar appearance, and in two or three days forming a roundish cluster o^ 
transparent vesicles, others at the same time continuing to appear nearly in a 
line from tlie stei-num to the spine on one side, or across the shoidder: in ten or 
twelve days they are covered with brown scales; sometimes an intense darling 
pain comes on at the close of the disease, scarcely to be allayed by tiie power 
of opium.* C. 



IJatcman's Uepcu-ts, l-Sl'J, p. iJ-4. 



254 THE MIXOK EXAXrilF,MATA. 

(See plate under cut. dis. vol. li. no. 18, div. iii.) The most 
frequent form of the disease is the herpes zoster, or shingles, 
in which the eruption appears on the abdomen, but is observed 
also in some cases on the extremities, or breast. Young persons, 
from fifteen to twenty-five years of age, are commonly the sub- 
jects of this disease. Very little is known regarding its causes. 
Anxiety of mind, change of climate, and irregular modes of life, 
are the circumstances which principally predispose to it. It is 
most frequent in summer and autumn, and seems in some cases 
to arise from exposure to cold after violent exercise. It is al- 
ways slight, seldom confining the patient to the house, or occa- 
sioning any debility. Its course cannot be shortened by inter- 
nal medicine, and it does not require any external applications. 
In hot countries, herpetic ringworms (herpes circinatus) often 
prove both tedious and severe, but in this country they follow 
the usual progress. That variety of the disease termed herpes 
labialis, occasionally appears as an idiopathic affection, origina- 
ting from cold and fatigue. It is then preceded for two or three 
days by nausea, lassitude, languor, and sometimes severe feverish 
symptoms. It is frequently symptomatic of some internal dis- 
order.* The common purgative draught, U. infus. senn. com- 
pos. 5x. pulv. jal. gr. XV. potass, supertart. ^i. syrup aurant. tinct. 
senn. au ^i. m. f. haust. repeated as circumstances may require, 
seems to comprise every thing that is really necessary in regard 
to the treatment of herpes. 

In g-eneralthis is true; in some violent cases tlie antiphlopstic trcivtmcnt is 
absolutely necessary; tlie application of fresh lard to the vesicles has sometimes 
a fine effect in cutting" short tlie disease. 

The decoction of bark is certainly useful in the severer cases, 
and may be given in combination with the liquor ammonite ace- 
tatis, if the secretions of the kidney are scanty. 

HERPES ON THE PREPUCE. 

Itchini^ and heat attract the attention to the prepuce; which exhibits small 
red patches, upon whicli are five or six minute red and transparent vesicles, 
which enlarg-e in 24 or 30 hours, and become milky, coherent, and pustular: if 
on the inside of the prepuce, so as to be ])rotected, tiicy break about the fourth 
or fifth day, and form an ulceration on each patch, which has a white base, 
edges slig-litly elevated, much resembling chancre, particularly if caustic has 
been ))reviously ap])lied. These irritants jiroduce inflammation, and deep 
seated hardness: when no application has l)cen made, the ulcei-ation, after con- 
tinuing for nine orten days, heals, and tlie scabs fall off' on the 13th or 14th day. 



* For more copious information concerning tliis ami the other diseases treat- 
ed of in this chapter, consult Hatcman's "Practical Synopsis of Cutaneous 
Diseases." London, 1813. 



THE MINOR EXANTHEMATA. 255 

When it occurs on the outer surface of the prepuce, the contents of the resi- 
des begin to dry about the fifth duy into a dry acuminated scab, and the part 
heals below by the ninth or tenth day,* the scab falling- ott" about that time. 

Generally, however, it appears that the friction of the clothes or the fingers, 
presents the complaint to our observation in the form of ulcer, with a yellow 
white plain surface, j- by the removal of the scab. 

The vesicles of this form of herpes are distinguished from chancre by the cir- 
cumstance, that there is no thickening of their basis; they resemble abrasions, 
only with the dirt'erencc of the white speck, presented on their removal. If 
caustics have been apphed, it exhibits the appearance of an irritable superfi- 
cial sore. 

There is another disease of the prepuce (venerola vulgaris) which deserves 
consideration; a pustule, dr}'ing on the spot, forming a larger and more solid 
scab than that formed in the above disease; the scab adheres closely to the sur- 
fiice, and if it be raised up it is attached by a stringy slough; a copious secretion 
of matter is also observed under it, which concretes on the scab already form- 
ed, and gradually enlarges it; when it separates an ulcer is discovered betow, 
which heals by granulation, t 

These diseases are usually the result of indigestion. Laxative medicines, 
with lead water applied to the part; if it do not speedily heal, the black lotion, 
which consists of calomel (1 dr. with 6 oz. of lime water,) may be substituted.^ 

Herpetic vesicles on the eyeUds, with smarting and itching, followed by 
inflammation of the conjunctiva, is treated best by gentle laxatives, and lead 
water. C. 

UllTICARIA. 

2. There are several kinds of eruption attended with fever, 
which have occasionally been mistaken for measles and scarlati- 
na. They are all very trifling diseases, but they deserve some 
attention on the score of diagnosis. One of these is the febrile 
Urticaria, or nettle-rash, fsee plate vii. under cutan. dis. div. 
iii. no. 17,) a rare disease, of which a very scanty notice will 
suffice. It is preceded for two or three days by feverish symp- 
toms. The eruption appears in the form" of white elevations of 
the cuticle, similar to those produced by the stinging of nettles, 
and denominated wheals. It is very itchy, especially during 
the night, or on exposing the skin to the air while undressing. 
It continues about a week, occasionally fading during the day. 
In children it is brought on by the irritation of teething, and at 
different ages by disordered states of the stomach and bowels. 

It occurs chiefly in summer, in the sanguine and plethoric, especially after 
taking improper food.H The pain and sickness are relieved as soon as the 
erujition takes place; it continues sometimes for years, but generally from one 
day to six weeks. Sometimes the wheals appear and disappear at short intervals; 
sometimes they are interspersed with small tubercles; at others they subside 
fi)r weeks and appear again. ^ C, 



Bat cm an. 


f Evans. 


iMimibe and Evans. 


§ Ibid. 


(iood, p.r>84-5. 


T Ibid. 



ioo THE mNOR EXANTHEMATA. 

Modifications of the febrile nettle-rash are induced in particu- 
lar constitutions by certain articles of food, shell-fish, almonds, or 
cucumbers. These cases are commonly attended with consider- 
able disturbance of the stomach, languor, and oppression. A 
gentle emetic, followed by a common opening draught, is all that 
is requisite in the treatment of the febrile urticaria. 

Honey, fruit, opium, herrings and lobsters when slightly tainted; certain fish 
within the tropics, as the herring and the yellow-gilled sprat, produce it: the 
morbid effects are confined to no part of the fish, do not depend upon copper 
infiltrated into its substance as has been said, and sometimes do not appear for 
a day after it has been eaten. 

The symptoms of this form ore, as the author states, weight and oppression 
at the stomach, nausea, vertigo, general uneasiness, numbness of some part of 
the'body, constriction of the tliroat, a senso of heat about the head and eyes 
followed by urticaria, and its appropriate itcliing, tingUng", and heated wheals, 
with great thirst, vomiting and diarrhoea. 

Sulphate of copper, as an emetic, gr. x. — jalap immediately afterwards as a 
purge — and after the emetic operates, twenty or thirty di'ops of aetlier to allay 
the iiTegular and general symptoms of uneasiness, are valuable. 

Vinegar, citric acid, and sugar taken with the fish are useful as antidotes. 

The infusion of serpentaria (3ii to the pint of water) is spoken of in a high- 
ly favourable manner in the common m-ticaria.* The itcliing may be allayed 
by camphorated vinegar rubbed on the skin; or cold water, applied on particu- 
lar parts at once. Dr. Willan describes a case in which tlic disease was fulul: 
The man was a great drunkard; fever and dehrium followed the fainting pecu- 
liar to it. 

The juice of parsley is celebrated as a nostrum, to be applied to the surface: 
It is useless. V. S. purgatives and salivation have been found to be injurious: 
whilst a digestible and antiplilogistic regimen of milk and water, whey, butter- 
milk, eating a little at a time and often, an entire change of the mode of living, 
of air, and sea bathing are the best plans. In old cases some oneai'ticle of diet 
offensive to the stomach is found to be the cause: It must be discovered by 
leaving off one by one the different accustomed articles of food. As fainting 
occurs generally where the eruption recedes, it is important to reproduce it: 
for this purpose, the warm bath, turpentine, blisters, and sinapisms to tlie skin 
are the best remedies: Several species of this disciuse are noticed by aulhoi-s, 
as the perstans or persistent, the coalescing or cbnferti; the diflerence is mere- 
ly inform: Tlie aq. kali puri eiglit or ten drops, three or four times a day; tlie 
white precipitate ointment applied to the skin, are useful; also the muriatic, 
sulphuric, and oxymuriatic acids, cascarilla tea, 5^^ ^o ^^^^ ^^^^^^ pi"^ ^f warm 
water. It sometimes is incurable. C. 

LICHEN. 

3. A disease much more frequently mistaken for the genuine 
exanthemata is Lichen; and in some cases the diagnosis is by no 
means easy. The cliaracters of the afiection may be tluis des- 
cribed. Lichenous eruption is papular, of a reddish colour incli- 
ning to purple, and exhibits, in many instances, tlie crescentic 
forms of measles. It is in chisters, and for the most part very 
copious about tlie hands and bendings of the wrist and elbow. It 



Cook'.- I'riK.llciil Treatise, p. '20'. 



OF THE SCAlilJVr l!iVi:iJ. 55r 

never advances to the formation of vesicles, but terminates, gene- 
rally at the end of three or four weeks, by slight desquamation 
of the cuticle. There is considerable variety however in the 
progress of lichenous eruption, as well as in the symj)toms accom- 
panying it. In many cases, the constitution appears quite unim- 
paired. At other times, severe febrile symptoms have been 
observed to usher the disease in, and to attend it for four or five 
days. There is always an unpleasant tingling and itching of the 
skin in lichen, increased by the warmth of the bed, and whatever 
else determines the l)lood with unusual force to the surface. It is 
not a contagious disease. It is taken indiscriminately by those 
who have, and those who have not, passed through measles and 
scarlet fever. Eruptions of a lichenous character arise from va- 
rious causes; sometimes from the heat of the atmosphere (consti- 
tuting lichen tropicus, or the prickly heat of hot climates), some- 
times from the venereal poison, but more frequently still, in this 
climate at least, from circumstances ill defined or altogether un- 
known. The disease, being wholly devoid of danger, may often 
be left to follow its own course; but saline aperients, low diet, 
and a cool regimen, are plainly indicated. 

The wann bath is recommended, and also tonics when the rash has disap- 
peared. 

Wilkinson speaks hig-hly of 5 or 6 grs. of carbonate of ammonia, every 4 or 
5 hours, with 5 grs. of calomel at bed time twice a week, and followed in the 
morning- by a piu'g-e. Aromatic vineg-ar diluted with one third water is to be 
applied to the itching- parts with a piece of lint wrapped round the probe and 
repeated every day or two: using- in the mean time tlie following- lotion. Am- 
mon. subcarbonat. and Plumb, superacetat. "^x. aq. rosar. 5iv, m. f lotio. The 
varieties of this chsease described by authors are the lichen tropicus or 
prickly heat; the simple (simplex); that which occurs in patches (circumscrip- 
tus); that which has a hair growing- from the centre of each pimple (pilaris); 
the more violent form attended with fever or the (agrius) to which the above 
treatment applies. These distinctions arise out of formal and not essential 
characters and are therefore not worthy of notice. C . 

4. A rash has been described by different authors as occasion- 
ally occurring in connection with febrile complaints, to which 
Dr. Willan has given the name of Roseola. It differs from lichen 
in being a mere efflorescence, of a rose colour, without papulae. 
One of the most common varieties of it, is that which precedes in 
many cases for one or two days the eruption both o( the mod ijied 
and inoculated small-pox. Occurring under such circumstances, 
roseola has frequently given rise to much discordance of opinion 
concerning the real nature of the case. A similar eruption has 
been very often observed during the summer months, in persons 
(especially females) of irritable constitution. 

PEMPHIGUS. 

The diseases of pemphigus and pompholyx are distinguished by the former 
being- attended with fever, whilst the latter has none. Lang-uor, lassitude, 
followed by fever, the eruption of vesicles from the size of a pea to that of a 
Vol. 'i 33 



258 or THE 5CAPvLET FEVER, 

walnut are the s}'Tnptoms of pemphigus: Sometimes the blister commences 
round a small brown point on the skin, produced by the rupture of a vessel; 
tlie vesicle enlarges, the blood tinges its iiuid of a brown bluish colour; gene- 
rally its contents arc simply serous: the vesicles are sometimes followed by 
sores, which are covered with scabs like rupia, or degenerate into ulcers: 

The vesicles affect the fauces and extend through the whole tract of the ali- 
mentary canal; great difficulty of swallowing, the ap})earance of vesicles in the 
mouth, distinguish it, when in the gullet; hiccup, pain in the stomach and nau- 
sea, vomiting a bloody matter, when in the stomach; general soreness in the 
abdomen witli bloody stools, when in the bowels: The vesicles after they heal 
on the external surface, leave pits like those of small-pox, the parts remaining 
for some time of a dark colour.* 

Swellings and abscesses of the parotid, inguinal and axillary glands, fre- 
quently accompany this eruption, which it is necessary to open early to secure 
the safety of the patient: "\Vhen the vesicles appear in considerable numbers 
in the alimentary canal, with a small wiry pulse, the danger is considerable: 
AVhere the surface of the vesicles becomes gangrenous, with typhous symp- 
toms, the danger is great: in general there is little cause for alarm where there 
is no fever, f The eruption sometimes is united with irregvdar forms of small- 
pox.t It occurs also without fever. Inoculation does not communicate it, as 
appears from the experiments of Dr. Hall.§ I have repeated them with the 
same result. 

Erythema and petechiae have been combined with it; it is sometimes epi- 
demic, and attended with heat, itclungand vesicles which appeared brown with 
a mild typhus relieved by saline and cooling medicines. Sometimes the symp- 
toms have been inflammatory and violent, with ophthalmia, and a copious flow 
of tears. II 

In the mild febrile variety, "purgatives, sudorifics, should be prescribed; when 
the dark serous vesicles appeal- witli low typhous symptoms, tonics and laxa- 
tives arc proper: . 

The inflammatory variety is to be treated according to the directions laid 
down under the head of Synocha; and in all cases the blisters are to be 0])en- 
ed and kept clear with mild mucilaginous washes; and when they affect the 
fauces and alimentary canal, with diluents, avoiding irritating purges, which 
might produce ulceration through the intestines, which might be fatal. 

This disease has appeared in Ireland as an epidemic among children. It as- 
sumed the typhous character, the fluid of the vesicle was pui-plish and turbid 
with pus sun-ounded with an inflamed border, and emhng' in sjjreading ulcers; 
skin livid; ulcers witli dark edges, great discharge and fcctor, excessive consti- 
tutional irritation after the bursting of the vesicles, with a rapid decline of 
strength, convulsions and death ; The ulcers destroyed the connexion between the 
cartilage of the ear,and the cranium, sprcadingjto the eyes and crown of the head.|| 
This epidemic evidently was a low fever with local determination, the result no 
doubt of bad air and unwholesome food. Poultices of oat me:U and porter, 
followed by an ointment made of the scrophularia nodosa or great fig-wort, .ap- 
plied to the ulcers witli good cflect: yeast givci\ internally was useful. || It was 
a typhous disease and trciited accordingly. ('. 

POMPHOLYX. 

PoMPnOLYx, with which it has probahly been confounded, is 
a chronic ailment, characterized by an eruption of bulla\, or vesi- 
cles of the size of walnuts, which continue to appear in successive 



* Philip, p. 344-5. I Ibid. p. 346. 

\ Sydenham on the small- pox of 1G70-1-2. 

§ I)\inran's Annals, 179'.). 

II Medical Kccor.h r, vol. viii. p. 87- 



or Tin: scaulli iKVKii Cj'J 

crops, occupying diflereiit parts of llic hod}-, but mure us[)cciall3' 
tlie extremities. (See plate under cutan. dis. 10, divis. ii.) TWni 
disease is unattended by lever. It often lasts a month or .six 
weeks, and aj^pears to be connected with some cachectic, or de- 
praved and debilitated state of the whole system. Pompholyx 
is particularly obstinate and severe in old people. It produces in 
them great itching and inconvenience, and from the extent of 
surface occupied by the eruption and the occasional intermixture of 
livid vesicles, presents, on some occasions, a very formidable as- 
pect. Medicine, as far as I judge from my own limited obser- 
vation, has very little power over it. 

It is to be treated as a cachectic disease^ in which the tone of the whole sys- 
tem, more particularly of the alimentary canal, is to be restored: Yeast, bark, 
wine, the mineral acids, sarsaparilla, pure air, exercise, purgatives, are most 
likely to benefit it. C. 

5. Closely allied to roseola, and scarcely indeed distinguisha- 
ble from it, is the eruption called by Dr. Willan erythcvia. It is 
characterized by a nearly continuous redness of some portion of 
the skin, with a slight elevation of the surface, speedily subsiding. 
The disease is not contagious, and the accompanying febrile 
symptoms are very slight. The principal species of the disorder 
is called erythema nodosum. The eruption is here confined to 
the fore part of the leg, and takes the form of large oval patches, 
which run parallel with the tibia, and rise into painful protube- 
rances, much resembling nodes. The eruption subsides in ten or 
twelve days, but usually leaves the patient languid. Mild laxa- 
tives, followed by the mineral acids, are sufficient for its cure. It 
is a singular circumstance, that this variety of erythematous erup- 
tion is seldom witnessed, except in females. It occurs principal- 
ly in the months of June and July. 

6. FRAMBffisiA, or the Yaws, deserves to be placed amongst 
the exanthemata, first, because it can be taken but once in life; 
and secondly, because it is propagated by specific contagion. It 
difiers from them however in having no fixed course, but wearing 
itself out in a longer or shorter time. It may be considered, 
therefore, as the link uniting the febrile exanthemata to the chro- 
nic cutaneous diseases, porrigo, scabies, and lepra. Framboesia is 
endemic in Africa and the West Indies, prevailing chiefly among 
negroes; but Europeans sometimes take it. It is preceded by a 
degree of constitutional disturbance, amounting, in some instan- 
ces, to fever. An eruption of small pimples then follows, in- 
creasing for ten days, when pustules form. To these succeed 
loose irregular crusts, beneath which, foul sloughy ulcers are to 
be found, which gradually shoot out a fungus, resembling in size 
and appearance a mulberry. This occurs at iri^cgular periods, 
sometimes as early as one month; sometimes as late as three from 



260 OF TIIK SCARLET FEVEK 

the appearance of the eruption. The disease in about eight months 
wears itself out. The fungus contracts, and except where the 
inflammation ran very high, cicatrizes, without leaving any scar. 
The general health is but little, sometimes not at all, impaired in 
the progress of the complaint. It is not a disease of danger. 

This, however, is not always the case; Sometimes the wretchedness of per- 
sons afflicted with the yaws exceeds belief: The symptoms grow worse from, 
bad living and improper food: 

Dr. Thomas describes the number and size of the pustules as proportional to 
the degree of fever on the first attack: Sometimes tlie tumours form upon the 
soles of the feet, where, from tiie tiiickness of the cuticle, they make their 
way to the surface very slowly and witii great pain, rendering the person lame. 

The yaws arises from a specific contagion, the latent period of 
which is seven weeks.* It may be propagated by inoculation, 
but the disease is not thereby rendered milder or shorter. In 
Africa, it is usually undergone, like the measles in this country, 
during childhood. It is altogether beyond the reach of medicine. 
Like the small-pox, it must run its course, and will leave the 
constitution, when, after completing its various stages, it removes 
the susceptibility to future infection. Towards its decline it ap- 
pears to be somewhat benefitted by sarsaparilla, bark and acid, 
and a generous diet. 

Little is known with regard to tlie treatment of this disease: Till it has 
come to its height, diet only is pro])er. A writer in the Edinburgh Journal 
recommends a bolus, composed of a scruple of sulphur and five grains of calo- 
mel, to be administered every night, when the disease is declining, avoiding 
salivation: The actual cautery applied to the tumors in the soles of the feet, 
after they have been softened by the application of wai-m water, has a good ef- 
fect; the diet must be nourishing but not stimulating, and sufficient in quantity. 
The use of lime water as a drink, with the articles recommended above, and 
gentle escharotics to the ulcers on the body, with more active substances of 
the same kind to the principal sores, embrace the whole treatment. C. 



• See Edinburgh Medical and Surgical Journal, July 1819, article by Dr 
Thomson. 



{ 261 ) 



CLASS III. 
PHLEGiMASl.E, OR INFLAMMATORY DISEASES. 



CHAPTER I. 

GENERAL DOCTRINE OF INFLAMMATION. 

Universality of Injiammation, — Symptoms of external In- 
ftamw,atio?i. — Pain, Heat, Redness, Swelling. — Symptoms 
of internal Inflammation. — Pain, disturbed Function. — 
Fever, huffy Blood. — Terminations of Inflammation. — 
Resolution, Effusion, Suppuration, Gangrene. — Predispo- 
sition to Inflammation. — Causes of internal Inflamma- 
tion. — Mechanical and Chemical Irritants. — Cold. — Mor- 
bid Poison and Contagion. — Metastasis. — Prognosis . 

UNIVERSALITY OP INFLAMMATION. 

Evert organ and structure of the body is liable to inflamma- 
tion; and, next to fever, this is the most important subject of 
inquiry in the wide extent of medical science. It involves seve- 
ral considerations of a general nature, which it will be for the 
advantage of the student to begin by pointing out. There are 
certain phenomena, for instance, observed to attend it in its pro- 
gress and decline, whatever be the organ or structure attacked. 
The causes of inflammatory action also are very much the same, 
whatever part of the body be its seat. The symptoms, termi- 
nations, and causes of inflammation, therefore, constitute its 
fundamental doctrines, and this chapter will be devoted to their 
consideration. In the next I shall advert to the varieties of in- 
flammation, whether occasioned by differences of cause, or func- 
tion, or texture of the part affected. Some remarks on the theo-^ 
ry of inflammation, and the principles of its treatment, will 
conclude the inquiry into the general doctrine of acute inflam- 
mation. Much interest, however, has lately attached to the 
subject of chronic inflammation; and it may not be foreign to 
our purpose to offer, in conclusion, a few remarks on that state of 
disease, such as may be sufficient to point out its principal patho- 
logical features. 



262 GENERAL DOCTRIN: 



SYMPTOMS. 



When any part of th^ body which is obvious to our senses be- 
comes inflamed, such as the skin, the tonsil, or the eye, there 
are four alterations from the healthy state of the part which be- 
come manifest. These are pain, heat, redness, and swelling. 
It is not any one of these symptoms singly, but their combina- 
tion, which marks the existence of inflammation. The stomach 
may be painful from distension. The skin may be hot from fe- 
ver. The cheek may be red from blushing. The breast may 
be swelled from the flow of milk. To determine how far each 
of these symptoms is to be considered an evidence of inflamma- 
tion, is an object of some importance. 

PAIN, HEAT, REDNESS, AND SWELLING. 

1. A certain degree of pain attends every deviation from 
health. Pain arises from spasm, fatigue, distension, sympathy, 
irritation, and along with other symptoms it is an important cri- 
terion of inflammation. At first the pain attending inflamma- 
tion is acute, or lancinating; afterwards it is a throbbing or pul- 
satile pain, and these varieties of pain indicate diflferent stages in 
the process of inflammation. The kind and degree of pain in 
particular cases appears to be proportioned rather to the facility 
of distension in the part than to the quantity of nerves with 
which it is supplied. 

2. The heat of an inflamed part is the least important and 
the most frequently wanting of all the characters of inflammation. 
It never can exceed that of the blood at the heart. It is most 
conspicuous, therefore, when inflammation attacks a part at the 
greatest distance from the centre of circulation; such as the great 
toe in gout, or the point of a finger in whitlow. There is rea- 
son to believe, that in the inflammation of internal organs, the 
heat of the part is not materially augmented. 

3. Increased redness of a part, if permanent, is nearly deci- 
sive of the existence of inflammation. We find it after death to 
have occurred equally in cases of internal inflammation. It is 
obviously owing to one of two causes, or ])erhaps to both, the 
enlargement of old vessels, or the growth of new ones. 

4. Swelling is an accidental symptom of inflammation, attri- 
butable to the degree of looseness in the structure and connexions 
of the part. Generally speaking, therefore, where there is least 
swelling there is most pain. Some structures of the body appa- 
rently inflame without any swelling at all. 

SYMPTOMS OF INTERNAL INFLAMMATION. 

Sucli are the signs of external inflammation, or phlogosis; but 
the physician has not, for the most part, tlic advantage which the 



UF INKI.AMMATION. 263 

surgeon possesses, of judging by the eye of the existence of this 
state of disease. The symptoms of internal injlamniation, 
or oi phlegmasia, are more obscure, and require more minute 
investigation. Its presence is judged of in two ways, — by local 
and by constitutional symptoms. The local symptoms are pain, 
increased on pressure, and disturbance of function; the constitu- 
tional fever, and bufliness of blood. 

1. Pain is the most important of them all; but in order to 
characterize it as the pain of inflammation, it must be increased 
on pressure. The test of pressure cannot, however, be applied 
in all cases; as in inflammation of the brain and bronchia, where 
a bony or cartilaginous case defends the inflamed structure. 
Pain again is not essential to constitute inflammation. Where 
tlie aflcction exists in an organ or very loose texture, there is 
little or no pain felt, as in peripneumonia. Cases have even been 
recorded, of inflamed brain and pericardium proving fatal witliout 
any such inconvenience being produced, as warranted the sus- 
picion of inflammatory action. 

Pain and irritation in distant parts are also proofs of llic existence of inflam- 
mation in certain organs; as, a diseased prostate is known by pain in the in- 
side of tlie thighs; inflammation of the liver hy a pain in the shoulder; of the 
scrofulous hip, by a pain in the knee; disease of the woml), by a weakness of 
the lower extremities, pain in the back and hips; a diseased state of the pylorus, 
by heat and pain in tlie throat; inflammation of the testicles, by pain in the 
loins.* Diseased actions in distant parts also show the state of inflammation in 
other parts; as, hiccup is the concomitxuit of incipient mortification; excite- 
ment of tlie blood-vessels of the head, in certain fevers, produces nausea and 
vomiting-; injuries of the brain have the same eflect:-|- Inflammation of the kid- 
ne3^salso produces vomiting: Convulsions in children are often the result of in- 
flammation of the covering membrane of a tooth, in dentition. C. 

2. Disturbance of function is almost a necessary concomitant of 
inflammation; and wherever the function of an organ is under- 
stood, we may judge of the extent of inflammation in it by the 
degree of disturbance which its function undergoes. The par- 
ticular symptoms referable to this head, are of course^as various as 
the organ attacked. Delirium marks inflammation of the brain. 
Impatience of light, ophthalmia. Hoarseness, inflammation of 
the larynx; and dyspnoea, that of the lungs. There are only a 
few cases on record of inflammation existing in a part without dis- 
turbing its function. 

3. Fever, more or less urgent, accompanies every kind of in- 
ternal inflammation. In degree it varies, froni the slight febri- 
cula which attends catarrh to the highest grade of inflammatorj^ 
fever, such as is witnessed in phrenitis. It diflbrs no less in kind 
than in degree. At one time it is inflammatory, at another ty- 

* Cooper. j- Ibid. 



264 ENEUAL DOCTIUNE 

phoid; in one instance it has a hectic^ in another a remitting 
character. It may be held as a general rule, that the degree of 
local inflammation may be estimated by the violence of the con- 
stitutional symptoms; but at the same time it must be borne in 
mind, that the degree of fever present in any individual case, 
does not always bear a proportion to the importance of the organ 
affected, or the extent of local disease. It may run as high in 
cynanche tonsillaris, as in a severe attack of pleurisy, and fre- 
quently appears to be measured by peculiarity of constitution. 

The degree of constitutional 'affection and nature of the fever varies very 
much in the org"an affected; thus, in plirenzy, the full, hard tense pulse is 
most generally found with other sig-ns of high fever; tlie inflammation of the 
heart, with abscess, has appeared without any violent symptoms; rheumatic in- 
flammation, when translated to this org-an, produces great prostration, anxiety 
and weakness, often a hard, rapid, and rather small than full, and sometimes an 
irregular pulse; it is sometimes incapable of being counted, at others is small, 
flying under the fingers and intermittent:* hi common carditis the pulse is 
hard. The inflammation of the stomach is almost always attended with a hard 
and small pulse: In the irritation and inflammation attendant on the passage of 
a gall-stone, as also a small calculus through the ureter, the pulse is unmoved, 
and keeps the regular pace of health :f so that it is difficult to estimate by any 
regular rule the effect upon the heart tind arteries of the inflammatory affections 
of the different organs. In a general way, from the effects produced by inju- 
ries upon one organ, as the skin, being propoilional to its size, it is evident that 
in some instances there is something regidar in this matter; this appears also 
from the influence produced by surgical diseases being proportional to their ex- 
tent; thus a compound fracture produces more violent symptoms than those 
which are simple; but, when it is recollected that the slightest injiu*y to a nerve, 
the puncture of a needle, will produce the most violent tetanus, tliis clue to di- 
rect our steps is not very certain; so that it is only by accurately attending to 
the state of the system, the causes and symptoms of chseases, as they will 
hereafter be detailed, that we can properly appreciate the connexion between 
the local affection and the general impression on the system. It will be found 
that the same general causes which aggravate fevers, have the same effect upon 
inflammation; thus, the systems of infants are less al)le to bear the irritation of 
fever in proportion as they are younger; this is true of the heat in this climate; 
the aged also die from weakness and fever produced by the extremes of tem- 
peratui-e; the same is true of inflammations: Intemperance has the same effect 
on the habit with regard to the power of supporting fever and inflammations: 
Excessive abstinence, and loss of rest, also render the system in-itable, and 
not 80 able to bear this process, t C. 

Some persons, from these data, have urged, not without an 
appearance of reason, that the fever accompanying local inflam- 
mation is not always a secondary affection; — that in cynanche 
tonsillaris, for instance, it is not the swelling of a small and in- 
significant gland which raises the pulse to 120; but that fever is 
the primary affection, which from some unknown cause induces 
the local inflammation. Where neither tlie constitutional nor 



• Scudamorc, 271. 12.1. London cd. 1827. 
I llcbeitlen, Med. Transact, vol. iii. p. 32. 

i Coojior. 



OF INFLAMMATION. 205 

the local symptoms are urgent, it is common with some physi- 
cians to employ tlie term sub-acute injlammation. In a pa- 
thological point of view nothing is gained by its adoption, but 
practically it is of some use, as for instance, in distinguishing 
and directing the treatment of some cases of bronchial and rheu- 
matic inflammation. 

4, The last proof of the existence of internal inflammation is 
derived from the appearance of the blood drawn. All ages and 
countries have agreed in looking upon buffiness of the blood as a 
test of inflammatory action; but different ideas have been enter- 
tained as to the degree of importance which should be attached to 
it. Boerhaaveand the followers of his school considered it as the 
decisive argument in favour of that lentor or spissitude of the 
blood, on which they believed inflammation to depend. Of late, 
physicians have rather been inclined to undervalue it as a symp- 
tom of inflammation. Upon a careful review, however, of all the 
arguments which bear upon this question, I am satisfied that 
huffy blood is a very important criterion of the presence of in- 
flammation. Genuine inflammation, indeed, sometimes exists 
without it, and the first cup of blood may be huffy when the last 
is not. These and other anomalies are interesting in a practical 
point of view, but they do not affect the general question of the 
pathological importance of bufliness of blood. The cause of this 
appearance has been a frequent subject of investigation. It has 
been supposed to depend upon the slower coagulation of the 
blood; but this is obviously insufiicient, for blood may coagulate 
slowly and not be huffy. That blood will prove huffy, may often 
be predicted from the bluish appearance which it exhibits while 
flowing from the arm. Some pathologists imagine, that the re- 
lative proportion of fibrine in the blood is augmented in a state of 
inflammation. Others attribute the phenomenon merely to in- 
creased rapidity in the blood's motion; forgetting that the blood 
is often deeply buffed with the pulse at eighty. The subject, it 
must be confessed, is still involved in great obscurity. 

TERMINATIONS OP INFLAMMATION. 

The progress of inflammatory action, generally described un- 
der the title of the terminations of inflammation, next claims at- 
tention; and here I must begin by observing, that whatever opi- 
nion may be formed regarding the precise condition of the blood- 
vessels in inflammation, it is obvious, from the general tenour of 
the phenomena now described, that they are loaded with an unu- 
sual proportion of blood. Of this they must be relieved, before 
the vessels can be restored to their natural healthy condition. 
The terminations of inflammation therefore consist for the most 
part of the several modifications o{ effusion. 

34 



266 GENERAL DOCTRINK 

1. When an inflamed part gradually regains its healthy state 
without any derangement of its structure, or any sensible effu- 
sion from its vessels, the disease is said to terminate by resolu- 
tion. This is invariably the object of the physician, but the 
surgeon is often baffled by it, because he occasionally excites in- 
flammation with a view of profiting by some of its subsequent 
stages. Resolution may happen, first, without medical aid, 
when the inflammation is very slight; and, secondly, when the 
requisite unloading of the diseased vessels has taken place by 
means of local or general blood-letting, or in milder cases by 
local cold and purging. We judge of the tendency to resolution 
by the gradual gi\in^ way of the symptoms of inflammation, 
particularly by the diminution of pain and fever. 

2. The second termination of inflammation is an increase of 
the natural secretions of the part. In membranes which have 
an external outlet, such as the several mucous membranes, this 
is almost equivalent to resolution. In the shut cavities, as those 
of the pleura, pericardium, and peritonaeum, such a termination 
of inflammation is more to be dreaded; but in many cases the 
fluid thus effused is gradually absorbed, and health ultimately 
restored. 

3. The third mode by which inflammation terminates, is effu- 
sion from the vessels of the part, either of blood or of some of its 
constituent parts. The mucous membrane of the bowels, when 
inflamed, frequently relieves itself by a discharge of pure blood. 
In some cases the serum of the blood is effused, as in hydroce- 
phalus and inflammation of the tunica vaginalis testis. In other 
cases the coagulating lymph oi the blood is effused, forming ad- 
hesions, as in pleurisy and peritonitis. A peculiar gelatinous 
fluid is thrown out in rheumatism, and a saline matter in gout. 
The consequences of these effusions vary according to the violence 
of the inflammation, and the situation and structure of the part 
affected. Adhesions from pleuritic inflammation are productive 
of little or no inconvenience; occurring in peritonaeal inflamma- 
tion, they lead to incurable marasmus or ileus. The effusion of 
serum from inflamed vessels forms a part, and a very important 
part, of the general pathology of dropsy, to which we shall here- 
after have occasion to refer. When effusion takes place in the 
substance of the solid viscera, they become hardened, and are 
rendered more or less unfit for the due performance of their 
functions. This is a frequent effect of chronic inflammation, 
and will be further noticed when discussing that branch of the 
subject. 

4. The fourth termination of inflammation is the effusion of a 
new product of the blood, called /;z/.v, a bland fluid, of the colour 
and consistence of cream. When this is poured out into some 
cavity formed during the process of inflammation, an abscess is 



OF IM LAMM A HON. 567 

said to exist; when the purulent matter forms upon an exposed 
surface, ulceration is said to be established. This subject opens 
an extensive field of inquiry; but it falls more properly within 
the province of surgery. By John Hunter and others, the dif- 
ferent topics which it embraces, more particularly the nature of 
ulcerative action, have been investigated with great success; 
and among other points, that remarkable analogy has been ex- 
plained which subsists between pus and a secreted fluid, between 
an ulcerating and a secreting surface. The formation of pus by 
internal inflammation exhibits nothing different from what occurs 
when the inflamed texture is in contact with the air. The symp- 
toms by which we judge of suppuration having taken place in 
an internal organ are the following: — 1. A change from the 
lancinating to the throbbing pain. 2. A sensation of weight 
or fulness in the inflamed part. 3. The pulse continuing fre- 
quent, but becoming soft and full. 4. The occurrence of rigors 
and of night sweats, — in other words, the development oUiectic 
fever. 

When an abscess is formed, the matter may be discharged either by the 
ulcerative process taking place on the surface, making an opening outwardly, 
or it may be absorbed, and taken into the system: in either case the sides of the 
cavity contract; gi-anulations, or small red points, rbe upon the internal surface 
and fill up the cavity: when most healthy they are of a florid red colour: when 
muscles and glands are the seats of abscesses, it is said that the new substance, 
which supphes their place, cannot perform the functions of the original parts; 
the skin, tendons, ligaments, nerves, bones, on the contrary, can be renewed, 
and perform their functions perfectly.* 

Pus is a straw-coloured fluid which sinks in water, of a uniform consistence, 
a mawkish taste, exhibiting' to the microscope, minute globules floating in a 
serosity: It is coagulable by a saturated solution of muriate of ammonia, but not 
by heat, forms a semi-pellucid, viscid, stringy substance not diffusible in wa- 
ter, when a caustic lixivium is added resembling in this state the mucus se- 
creted by the bladder in ceilain diseased stat&s of that viscus. It is inodorous 
when cold, when warm it has a peculiar smell, and is often disagreeable; is not 
coagulated by diluted acids or by alcohol when pure; but when acted on by 
alkalies, it is easily coagulated by these substances: The precise differences 
between serum, mucus, and pus, however, are not yet sufficiently ascertained. 
Its specific gravity is gi-eater tlian that of water; it is not readily diffused in 
cold water, though in warm it is; it does not readily putrefy. 

Pus is distinguished, 1. From chyle, by its not coagulating on exposure to 
the air, and a high temperature, and by its globules being larger: 

2. From milk, by the globules being more numerous, though nearly of the 
same size; pus does not coagulate by runnet, milk does; milk contains oil and 
sugar, which pus does not: 

3. From pancreatic juice, by the globules of pus being larger: 

4. From the discharge of ill conditioned sores, by the flaky matter which that 
discharge contains: 

5. From that of blisters, by the latter containing neither flakes nor globules. 

6. From mucus, by the properties peculiar to pus, above enumerated; 
when mucus is formed in cavities, to which the air is not admitted, it is hea- 



* Philip, p. 41. 



268 GENEHAL DOCTKINE 

vier than water; and even if it is formed in contact with tlie air, it becomes 
heavier, if allowed to become dense by stag-nation and the absorption of its 
more fluid parts. Mucus expectorated in the morning is often heavier than 
water; and if pus be mingled with air, it swims.* Mucus when mingled with 
water gives to it an appearance of stringy portions of substance floating- through 
it; pus renders water uniformly turbid; sulphuric acid dissolves mucus more 
readily than pus; if water be added to these solutions, the mucus swims through 
it in flakes, whilst the pus falls to the bottom: Caustic potash dissolves both 
pus and mucus; when water is added, the pus falls to the bottom, but the mu- 
cus is not separated. -j- 

The formation of healthy pus, such as is above described, is attended witli 
feelings more or less comfortable in the general system, natural secretions, 
skin, and look of the countenance; all general causes, wliich have a tendency 
to derange the system, aflectthe state of this fluid; thus, Mr, Hunter observed 
that a sudden change in the air produced instead of pus a layer of coagulable 
lymph, like melted tdlow, adhering closely to the surface of sores: The more 
distant the sore is from the heart, the more likely is it to deg-enerate in its qua- 
lities; and the more pure it is, the less it erodes the animal solids; pure piis has 
no effect in this respect: 

Diet has a great eff'ect upon the character of pus; thus a moderate diet in a 
healthy system preserves its healthy qualities; reduce it, and it becomes serous, 
bloody, as the weakness increases: A diet too stimulating renders it bloody, 
sanious also in proportion as it is increased; other causes, as the state of the air, 
tlie mind, ])roduce changes in it. t C . 

5. The last and the most formidable of all the terminations of 
inflammation is sloughing, sphacelus, gangrene, or mortification, 
which are only different degrees of the same morbid condition. 
This happens, first, from the excessive violence of the first stage 
of inflammation, rendering it impossible for the vessels to restore 
themselves by any kind or degree of effusion. But as the ten- 
dency to gangrene often shows itself early, and without any par- 
ticular violence of the first stage, it must be ascribed, secondly, 
to a septic tendency in the disease itself, as in the case of plague. 
The malignity of that contagion so overpowers the nervous sys- 
tem, that the vessels of the inflamed part are unable to resist the 
shock of the disease, and the part itself dies. Thirdly, the dispo- 
sition to gangrene is, in many instances, independent both of the 
nature and of the violence of the inflammation, and is referable 
simply to the weakness of the patient's habit, which is such as to 
be unable to oppose resistance even to a mild attack. The 
symptoms of internal gangrene are: — 1. The sudden cessation of 
pain. 2. A sinking and irregular pulse. 3. A change in the 
expression of countenance from that of febrile anxiety to exhaus- 
tion. !4. Delirium. 

K 
When the gangrene is external the part becomes yellow, then greenish, 
then of a livid hue, the cuticle separates and forms blisters; the part becomes 
less tcMsc, swelled and hard, with a sense of crepitus on touching it: It is then 



• Philip, p. 39-40. j Cooper. 

+ Philip, on feb. dis. p. :>f', 40, vol. 2. 



0¥ INFLAMMATION. 269 

said to be in a gungreuous btate, and when It becomes completel/ black, wiili- 
out feeling or heat, it is denominated sphacelus. 

When it is not attended witli any discliarge, it is called the dry gangrene, or 
necrosis: Internal gangrene is always fatal; when external, it is often so: Inter- 
nal gangrene often kills by hacmon-hage from the opening of a large blood- 
vessel: When it is external, the means are more easily applied, and therefore 
tliey are more frequently successful; Sometimes the patients feel themselves 
quite well, on the coming on of gangrene: and sometimes it takes place with- 
out a cessation of pain,* C. 

It remains to be stated, that several of these terminations of in- 
flammation may be going on at the same time. Thus a mucous 
membrane may throw out a muco-purulent fluid. Flakes of 
coagulable lymph may float in the serum which an inflamed peri- 
tonaeum has thrown out. The destruction of the part may be 
gradual and partial, and it is then eaten away by sloughy, or 
what has been called phagedoenic ulceration. 

If the pain, inflammation, and derangement of function and g-eneral fever be 
unusually obstinate, suppuration is generally the result: if very violent, sphace- 
lus; Some organs, as the lungs and liver, are more subject to suppuration; 
others, as tlie stomach and intestines, to gangrene : However, sometime^ there 
is violent inflammation in the stomach without vomiting or pain; even the heart 
is said by Morgagni, to have been inflammed without either pain or injury of 
function ;j- tlie same also takes place in the intestines and the brain, C. 

Proceeding next to investigate the causes of inflammation, I 
shall first direct my attention to the circumstances which predis- 
pose to internal inflammation; and shall then point out the prin- 
cipal exciting causes of that state of disease. 

PREDISPOSITION TO INFLAMMATION. 

Inflammatory afiections occur in all climates, and to all ages, 
temperaments, and conditions of body; and there is consequently 
no small difficulty in determining the true nature of the diathesis 
phlogistica, or that particular state of body in which inflamma- 
tory action is most easily lighted up. Dr. Cullen states, that the 
inflammatory diathesis chiefly prevails in systems of the greatest 
vigour. A full habit of body, a plethoric state of vessels, and 
tension of fibre, are the terms usually employed to express the 
state of the system, when predisposed to acute inflammation. It 
cannot be disputed, that in such habits we often meet with ge- 
nuine inflammatory diseases; but the student must bear in mind 
that this is neither the only state of body in which they occur, 
nor is it even the most common. He will find, that when the 
constitution is below par, when it has been weakened by previ- 
ous diseases, by low living, by anxiety of mind, by excessive 
bodily fatigue, continued for a long period of time, inflammation 
of the most acute kind is often excited, which runs as rapid a 



Phihp, p. 59, vol. ii. f Ibid. 



270 GENERAL DOCTRINE 

course, and is attended with symptoms as violent, as inflamma- 
tion occurring in persons full of blood, and of the most robust 
habit. The state of weakness then, of iry^it ability, and o^ atony, 
is at least as favourable to the development of inflammation as 
that of plethora and tension. The state intermediate between 
these two is that which affords the surest preservative against the 
attack, not only of inflammatory, but of every other description 
of disorder. To that kind of inflammation which occurs in ro- 
bust habits, the term entonic has been applied; atonic to that 
which takes place in a reduced state of the system. As expres- 
sive of a pathological principle, these terms are not objectiona- 
ble; but the student must remember that they are inapplicable in 
practice, inasmuch as the several kinds of inflammation are to be 
treated on the same general principles. It is only with reference 
to prognosis, and the extent to which measures of depletion are 
to be pushed, that the study of the predisposition to inflamma- 
tion is practically useful. 

CAUSES OF INTERNAL INFLAMMATION. 

With respect to the exciting causes of internal inflammation, 
it may first be stated, that occasionally we can form no con- 
jecture as to the true cause of the complaint; but at other times 
we can define it with considerable certainty; and among the most 
important causes of internal inflammation will be found the fol- 
lowing; — mechanical and chemical irritants; cold; a peculiar ha- 
bit of body, formerly characterized as a depraved state of the 
blood and humours; the presence of a morbid poison; contagion 
and metastasis. 

MECHANICAL AND CHEMICAL IRRITANTS. 

The phrenitis of infants has been traced to the irritation of 
teething; gastritis to poison; enteritis to the presence of harden- 
ed faeces; nephritis to calculus in the kidney; ophthalmia to dust 
and sand; erysipelas to leech-bites, or the distension of the" skin 
from dropsy. 

COLD. 

2. Cold is the most important of all the exciting causes of in- 
ternal inflammation. There is scarcely any form of it which does 
not occasionally owe its origin to cold; and many inflammatory 
affections, as rheumatism and pleurisy, have no other cause of 
the smallest practical importance. The period of time that elapses 
between the application of cold and the occurrence of inflamma- 
tory symptoms is subject to great variety. In the case of sore 
throat, it often follows in the course of a few hours. In tliat of 
acute rheumatism, a week, or even a fortnight, has been known 
to elapse. What the circumstances are which direct the inflam- 
mation upon one organ or structure rather than another, may be 



or INFLAMMATION. 271 

gathered, to a certain extent, from what has already been stated 
when treating of fever (page 77). In what manner cold operates 
as the cause of internal inflammation, has been a constant subject 
of inquiry with all pathological writers, but it is still involved in 
the greatest obscurity. 

MORBID STATE OP THE HUMOURS. 

3. Some forms of inflammation, which to a superficial observ- 
er might appear to arise without any assignable cause, have their 
origin in a peculiar state of l)ody, the nature of which is not al- 
ways understood, but which the older physicians supposed to 
consist in some morbid state of the Jluids or hiimours. This 
piece of pathology is exemplified in the phenomena of gout; in 
the inflammation of absorbent glands occurring in scrofulous chil- 
dren on the approach of winter; and in the pustular eruptions, 
called acne, to which young persons are subject about the age of 
puberty. The mere presence oi fever unquestionably leads to 
local inflammation; and hence it is, that in the progress of typhus, 
thoracic or abdominal inflammations so frequently supervene. 

MORBID POISON. 

4. The existence of a morbid poison in the system is a fre- 
quent occasion of internal inflammation. This principle we have 
already had ample opportunities of illustrating in the phenomena 
of the plague, small-pox, measles and the other exanthemata. It 
is equally exemplified in those of secondary syphilis, where the 
inflammation of the fauces, or of the iris, or of the joints, is ob- 
viously attributable to the presence of a morbid poison. The bite 
of the rattlesnake excites a peculiar kind of inflammation in the 
cellular membrane. Anatomists frequently suffer from the ab- 
sorption of matter formed in the course of disease, especially of 
acute disease, such as peritonitis. In irritable habits this indu- 
ces not merely inflammation of the glands and cellular mem- 
brane, but also of the pleura and peritonaeum, often of the most 
acute and dangerous kind. Closely allied to this, in a patholo- 
gical view, is the important but well-ascertained fact of the ori- 
gin of many inflammatory afiections from contagion. There is 
a species of contagious catarrh. Two species of cynanche are 
contagious. There is a contagious form of ophthalmia. Ery- 
sipelas is contagious under certain circumstances; so in all pro- 
bability is dysentery. There is reason to suspect that one of the 
forms of peritonaea! inflammation is occasionally propagated in 
the same way. 

METASTASIS. 

5. The last cause of internal inflammation which it will be 
necessary to notice in this general view of the subject, is metas- 



272 GENERAL DOCTRINE OF INFLAM>IATION. 

tasis, or the translation of inflammation from one organ or 
structure to another. This is a very curious point in pathology, 
sufficiently established indeed as a matter of fact, but the rea- 
sonings concerning which are hitherto very obscure and imper- 
fect. It is exemplified in the ophthalmia which succeeds gonor- 
rhoea; in the inflammation of the testicle which succeeds the 
mumps; in the inflammation of the pericardium which succeeds 
rheumatism; in the inflammation of the brain which succeeds 
erysipelas of the face. In what manner the metastasis is efiected 
has never yet been developed. It appears, however, that to 
sympathy from similarity of structure something may be re- 
ferred; for in most cases of metastasis, it will be found that the 
structures primarily and secondarily afiected have an affinity to 
each other. 

In forming an estimate of the degree of danger in any case of 
internal inflammation, the student will keep chiefly in view the 
nature of the organ attached, i\\Q strength of the patienVs 
constitution, and the length of previous illness. Inflamma- 
tions which arise suddenly and unexpectedly, occur for the most 
part in structures not essential to life, and are comparatively of 
little danger. Of this kind are inflammations of the pleura, of 
the tonsils, of the joints, and of the testicle. On the other hand, 
all those inflammations which are preceded by a long course of 
previous languor and ill health, occur in organs which are essen- 
tially necessary to life — such as the larynx, the pericardium, the 
bowels or the brain, and these are attended with the utmost dan- 
ger. Attention therefore to the previous history of the patient 
is an indispensable step towards forming a just notion of the de- 
gree of danger, as well as of tl^e necessity that may exist for 
prompt and active remedies. 



( 273 ) 



CHAPTER II. 

GENERAL DOCTRINE OF INFLAMMATION (CONTINUED). 



Varieties of Injlammation. — From the situation and func- 
tion of the part affected. — From Differences of Texture. — 
By ivhom first investigated. — Inflammation of Cellular 
Membrane and Parenchyma. — Of Serous Membrane. — Of 
Mucous Membrane. — Of the Skin. — Of Fibrous Mem- 
brane. — Varieties of Inflammation from Differences of 
Cause. — Theories of Inflamm,ation. — Jigency of Blood-ves- 
sels. — Of Nerves. — Question as to Differences in the Nature 
of Inflammatory Action. — General System of Treatment 
in Acute Inflammation. — In the states of Suppuration 
and Gangrene. 

VARIETIES OF INFLAMMATION. 

The study of the varieties of internal inflammation is no less 
important, in a practical as well as pathological point of view, 
than that of the oTeat features of ^t^^^wZ) /a?? ce which all inflam- 
mations bear. Some of these liavc been long known to, and 
amply described b)^ medical writers. Others have only attract- 
ed attention in the course of the last twenty or thirty years, and 
are not yet described with that accuracy of which the subject is 
susceptible, and which, from its immediate application to prac- 
tice, it deserves. The specific distinctions among inflammations 
may be reduced to the three following: — 1. The situation and 
function of the part inflamed. 2. The structure of the part in- 
flamed. 3. The exciting cause. 

FROM THE SITUATION AND FUNCTION OF THE PART AFFECTED. 

1. The first source of variety in inflammatory aflections is 
the situation and function of the organ inflamed. This is an ob- 
vious practical distinction; and it was accordingly noticed by all 
the oldest writers on physic. It is but of small importance, 
however, in a pathological view; for an organ is composed of 
dlficrent parts or textures, and each of these is liable to an in- 
flammation which exhibits some peculiarities. Though on com- 
mon occasions therefore it is suflicicnt to speak of inflammation 

Q>5 



274 GENERAL DOCTRINE 

of the eye, or of the lungs, or of the bowels, yet in a scientific 
inquiry, it is necessary to be more precise, and to speak of in- 
flammation of the conjunctiva, or of the iris, or of the tarsi; or 
to mark a distinction in the other cases by the terms, pleurisy, 
peripneumony, inflammation of the peritonaeum, or of the mu- 
cous membrane of the intestines. 

FROM DIFFERENCES OF TEXTURE. 

2. The second, and by far the most important of all the sources 
of distinction among inflammations, is to be found in the struc- 
ture of the part inflamed. Every part of an animal body, the 
cuticle and hair excepted, is subject to inflammation, and accord- 
ing to its structure, is inflammation occuring in it, modified both 
in symptoms and termination. It is an important and well-as- 
certained fact, that inflammation, in by far the larger proportion 
of cases, is confined to one texture, that it spreads along that one 
without affecting other contiguous textures; and that almost all 
extensions of it from one tissue to another are to be viewed as 
casual exceptions to a general law. For a long time this subject 
was either altogether overlooked, or but very slightly attended 
to b)^ pathologists. Dr. Carmichael Smyth has unquestionably 
the merit of l3eing the first who thought deeply, a,nd wrote ex- 
pressly upon it.* The views which he took of this great ques- 
tion are highly ingenious, extensive, and accurate. Subsequent 
observation, indeed, has corrected some, and enlarged others; 
but, upon the whole, they may be considered as constituting the 
basis of all our reasonings concerning tlie varieties of inflamma- 
tion. John Hunter and Bichat pursued the same track of inqui- 
ry. It was the fault of the latter author that he perhaps refined 
rather too much upon it. 

Physiologists reduce the fundamental textures of the body to 
five: — viz. cellular membrane, serous membrane, mucous mem- 
brane, skin, and fibrous membrane; and accordingly, there are 
five varieties of inflammation founded on peculiarity of structure: 
viz. phlegmonous, serous, mucous, erysipelatous, and rheumatic. 
A very brief sketch of the distinguishing characters of each of 
these forms of inflammation is all that is consistent with the plan 
of this work. 

INFLAMMATION OF CELLULAR MEMBRANE AND PARENCHYMA. 

1. That texture of the body which is the most generally dif- 
fused is cellular membrane, under which head physiologists in- 
clude, not merely the membrane strictly so called, but the pn- 



\"ulc '• Mfd'ifftl ('()ii»nmi)lratioiis," vol. 11. pngn- 16S. I^omlon, 17K8. 



OF 1 NFL. VMM A !1')N. 27 J 

renchyma of the diflerent solid viscera and glands, which consist, 
of cellular membrane connecting a congeries of minute blood 
vessels and nerves. The inflammation of cellular membrane is 
called phlegmonous or common inflammation, and its peculiari- 
ties are probably referable to the lax texture of the part, and the 
size of its arteries. Phlegmonous inflammation is distinguished 
by the great swelling which attends it, by its throbbing j^ain, 
and by its tendency to circumscribe itself and ultimately to form 
abscess. The process by which phlegmonous inflammation is 
circumscribed appears to consist in the effusion of coagulable 
lymph, uniting the cells together, and becoming afterwards the 
"walls of the abscess. To this order of inflammations belong pe- 
ripneumony, cynanche parotidoea, nephritis, hepatitis, and some 
others. Phlegmonous inflammation which terminates by slough- 
ing is called carhmicle. 

In particular habits of body, and under circumstances not al- 
ways well understood, cellular membrane inflames without 
showing any disposition to circumscribe itself. This constitutes 
what has been called diffuse cellular inflam^rnation, which has 
lately attracted much attention from pathological writers.* It 
occurs principally in debilitated states of body, or from some 
unusual malignity in the exciting cause. 

Carbuncle is a sloughing- phlegmonous abscess, which occurs \\\ an irritable 
state of the system from excessive stimulation, excesses in eating and drink- 
ing, and more particularly where the system has been debilitated by age; It is 
a symptom in the plague and other fevers. 

OF SEROUS MEMBRANE. 

2. Serous or diaphanous membranes are distinguished by a 
degree of transparency, by their firm and close texture, and by 
their function — the secretion of a serous fluid. The great serous 
membranes of the body are the tunica arachnoides, the pleura, 
pericardium, and peritonaeum. Though possessed of little sen- 
sibility in the healthy state, these membranes are the seat of 
acute pain when inflamed. Lancinating pain, therefore, is the 
first character of serous inflammation. It is attended by a 
hard^wd, wiry pulse, and a remarkable whiteness of the tongue, 
but for the most part without corresponding febrile debility. 
The peculiar terminations of this variety of inflammation are, the 
exudation of coagulable lymph forming praeternatural adhesions, 
— the effusion of serum into the cavities lined by the membranes, 
forming dropsy; — and occasionally the secretion of pus. It was 



* See a vahuible paper, by Dr. Duncan, junior, in tiic first volume of the 
Transactions of the Medico-Cliirurgical Society of Edinburgh. 



276 GENERAL DOCTRINE 

at one time a matter of doubt whether pus could be formed, ex- 
cept by the sides of an abscess, or by an ulcerated surface; but it 
is now well understood, that both serous and mucous membranes 
in a state of inflammation occasionally throw out true purulent 
matter. 

OF MUCOUS MEMBRANE. 

3. The mucous membranes are those which line the various 
passages and cavities of the body which have an external outlet. 
They secrete a mucus for the protection of their surface from the 
air, or the acrimony of the fluids which may come in contact 
with them. Their surface is villous, and interspersed with 
the orifices of glandular follicles. There are three great tracts 
of mucous membrane, — those, viz. of the nose, laVynx, and bron- 
chia; of the mouth, stomach, and intestines; of the urethra and 
vagina. 

When a mucous membrane inflames, its natural secretion 
either ceases, or becomes depraved, appearing thin, acrid, puri- 
form, or even purulent. It acquires an increase of irritability; 
but the pain which is present is slight in comparison with that 
experienced from the inflammation of a serous membrane. The 
fever which attends it is, in like manner, seldom of so acute a 
kind, but it is sometimes accompanied with a remarkable degree 
oi debility, which continues through a protracted period of con- 
valescence. In respect of termination, a curious diflference exists 
in the difierent tracts of mucous membrane, attributable proba- 
bly to some peculiarity in their anatomical structure. The intes- 
tinal tract is remarkably prone to ulceration, and the rapidity 
with which it runs into this state is worthy of note. The mem- 
brane lining the trachea throws out, during inflammation, coa- 
gulable lymph; that of the urethra, pus. These and other charac- 
ters of viucous injlainmation we shall afterwards illustrate 
more fully, when treating of ophthalmia^ catarrh, bronchitis, and 
dysentery. 

OF THE SKIN. 

4. Closely allied to a mucous membrane, in point of texture 
and function, is the skin; and the inflammation of this structure 
is attended with some interesting peculiarities. The phenome- 
na of small-pox prove that the skin is susceptible of j)hlogmo- 
nous inflammation; but the genuine inflammation of tlie skin has 
peculiar characters, which have acfjuircd for it the name of ery- 
thematous, or more properly o^ erysipelatous inflammation. It 
is characterized, like jjlilcgnion, by pain, heat, tension and red- 
ness; but instead of a tendency to circumscribe itself, its disposi- 
tion is to spread; instead of abscess, it goes on to the formation of 



OV IMLAMMATION. 277 

vesicle; and it occurs, much more frequently than other kinds of 
inflammation, in weak, irritable, relaxed, and exhausted states of 
constitution. 

The membrane lining the mouth and fauces being covered by 
a cuticle, may be considered as a continuation of the skin. It is 
equally susceptible of erysipelatous inflammation, leading, espe- 
cially in children, to the formation of those vesicles known by 
the name of aphthx. The inflammation produced by blisters, 
burns, and scalds, and the areolae of small-pox and cow-pox, arc 
instances of erysipelatous inflammation; closely allied to which 
also, are the eruptions of measles and scarlet fever. The true 
seat of the redness in all these cases is the vascular net-work 
called rete mucosum, the vessels of which in the healthy state 
do liot carry red blood. In the facial capillary system, however, 
the disposition of these vessels to receive red blood is very 
great, as is manifest in the phenomena of blushing. On this 
principle we account for the fact, that the exanthematous erup- 
tions begin about the face and neck; that erysipelas is so much 
more common and dangerous in the face than in any other part; 
and, as was formerly mentioned, that small-pox is most liable to 
become confluent on the face. 

OF FIBROUS MEMBRANE. 

5. The last structure which demands attention is that oiflh^ous 
membranes, a class of membranes whose physiological relations 
were first investigated by Bichat. It must be admitted, that in 
this arrangement there is some mixture of hypothesis, but still 
there appears to be a foundation for it in nature. Fibrous mem- 
branes have a dense structure, and they do not exhale. They 
have the periosteum for their base. The dura mater, tendinous 
and aponeurotic expansions, and capsular ligaments, come under 
his head. Synovial membranes are usually classed by physiolo- 
gists with the serous, but in di pathological view they may with- 
out impropriety be arranged here. 

Inflammation of fibrous membranes is commonly called arth- 
ritic, or rheumatic inflammation^ the peculiarities of which 
have been very long known. It difiers from common inflamma- 
tion in several points. 1. It never terminates in abscess, or 
adhesion, or gangrene, though the local symptoms be ever so 
severe; but it is followed by gelatinous exudation, or earthy or 
saline depositions about the sheaths of tendons, and the ends of 
bones, impeding motion in the parts. 2. It is generally slower 
in its progress than the inflammation of other structures. 3. It. 
has a remarkable tendency to sudden shiftings, or metastases. 
4. The accompanying fever has a peculiar character, which will 
hereafter be pointed out: the functions of the brain, for instance, 
are never affected in it. 5. It rarely proves fatal. 



.'SrS GENERAL DOCTRIXE 

The synovial membranes, classed by the author under tliis head, chfVer ma- 
terially from the ligaments, in being- liig-hly susceptible of inflammation, and 
suppuration; in scrofulous persons, particularly, these membranes are liable to 
become inflamed, and the cartilages which they cover are absorbed by ulcera- 
tion, whilst the ligaments surrounding the joint are tliickened, producing great 
enlargement of the joint: 

The inflammation of the fasciae is always severe; Thus, if from any cause the 
fascia lata becomes inflamed, the constitutional reaction is always considerable ; 
it is sometimes mistaken for erysipelas, from the irritation which it communi- 
cates to the skin;* When inflammation is seated under the sheaths of the 
tendons, or the fasciae, which cover the palms of the hands and soles of the 
feet, the pus formed upon them cannot get out, and from the distension travels 
from one part to another, under these membranes, producing excessive pain 
and constitutional irritation and fever. C. 

VARIETIES OF INFLAMMATION FROM DIFFERENCES OF CAUSE. 

Such are the chief structures of the body, and such the respec- 
tive characters of the inflammation which attacks them. It re- 
mains to be stated, that the exciting causes of inflammation exert 
a considerable influence over the character of the disease. Thus 
inflammation of the tunica conjunctiva exhibits different appear- 
ances, according as it originates from cold, or from contagion. 
Inflammation of the tonsils has a different aspect when it arises 
from the presence of the venereal virus in the system, from that 
which it assumes when it is owing to cold, or the contagion of 
scarlatina. The practitioner of experience can indeed often as- 
certain the cause, by observing the appearances of the disease. 

THEORIES OF INFLAMMATION. 

Many theories of inflammation have been proposed; many 
attempts, that is to say, have been made to explain the precise 
nature of inflammatory action. But inflammation is an action 
peculiar to life. It is on a par with secretion and absorption; 
and if we cannot unfold the nature of the healthy vital actions, it 
is not surprising that pathologists have failed in explaining those 
which occur in disease. It is pretty well agreed, that inflamma- 
tion is a morbid action of capillary vessels. This portion of the 
great circulating system appears to act a very important part in 
almost all the operations of the animal body. The capillaries are 
probably the organs mainly concerned in secretion and the growth 
of parts, and possibly also in absorption; but the whole subject 
of the functions of the capillary system is exceedingly obscure. 
Bichat appears to have considered it as altogether beyond our reach. 
Uninfluenced by these considerations, many modern pathologists 
have attempted to defme accurately the state of the capillary ves- 
sels during inflammation. All are agreed, that under such cir- 



Cooi)ci 



OF INFLAMMATION. '279 

cumstancos tlie blood-vessels of the part carry an unusual .propor- 
tion of blood; but some attach to this the notion o[ an increased 
action of their coats; others imagine, that in some part at least of 
their course, there is a spasmodic constriction; while a third 
class of pathologists maintain, that during inflammation the ac- 
tion of capillary vessels is dirninished. Into the merits of these 
different theories I have no intention to enter, after the opinion 
which I have expressed as to the almost impenetrable obscurity 
of the subject. The theory of increased action of the capilla- 
ries is, upon the whole, that which is likely to prove the most 
useful guide in practice; and, though by no means free from 
objections, will, with these reservations, be employed hereafter, 
wherever the nature of the subject may lead to theoretical dis- 
cussions. 

AGENCY or BLOOD-VESSELS AND NERVES. 

In the common theories of inflammation, every thing is attri- 
buted to the agency of blood-vessels. It is a matler, however, 
deserving of some inquiry, how far the nerves are concerned in 
inflammatory action. Several circumstances tend to the notion, 
that a huffy state of the blood is a phenomenon depending on ner- 
vous influence; but it would be out of place to enter upon the 
consideration of such obscure and difficult questions here. Nor 
do the^e comprise the only points concerning inflammation on 
which pathologists have difiered. A doubt has been expressed, 
whether differences of anatomical structure are sufficient to ex- 
plain all the diversities which we observe in inflammatory action. 
It has been suggested, that is to say, that there may be differen- 
ces in the nature of inflammatory action; that the same set of 
vessels may at one time be in a state of phlegmonous, and at ano- 
ther erysipelatous, or rheumatic inflammation. This refinement, 
however, appears to be unnecessary. 

The general principles of treatment in inflammation admit of 
being laid down with some accuracy; but they are of course va- 
ried by many circumstances, among which the most important 
are, the period or stage of the disease; the habit of body; the ex- 
citing cause; and the structure of the part inflamed. 

TREATMENT. 

1. The indications of cure in the early periods of internal in- 
flammation are, first, to unload the vessels; secondly, to lessen 
the visa tergo, the force of the heart's action; thirdly, to excite 
the vessels to a more healthy action; and, fourthly, to alter, if 
possible, the inflammatory condition of the blood. These indica- 
tions are to be fulfilled by the nicely-regulated employment of 
blood-letting, general and local; purging, refrigerant medicines, 



280 ' CiENKIJAT, DUCTUINE 

and the local application of cold; oo.casionally by blisters and 
warm fomentations; and, in a "few cases, by stimulants and tonics. 
The choice of the particular means best adapted to the different 
inflammatory affections of the body will be a principal object of 
inquiry hereafter. 

Inflammatory diseases differ from common remittent and intermittent fevers; 
1. in being less complicated in their nature; 2. in being more susceptible of 
relief from bleeding; and requiring the more cautious use of stimuli. 

3. In remittent fevers, too mucli depletion produces the low or typhous 
state; in inflammatory diseases, gangrene or local chronic diseases are tlie re- 
sult, particularly in tlie weak or the aged. 

In some, as angina malig'na, gangrene appears rapidly; in others, as pleurisy, 
suppuration is the more common effect; in rheumatism, the cflusion of serum 
is met with more frequently, and suppuration hardly or ever takes place: 
whereas, in remittents, though each of these terminations are occasionally met 
with, yet, generally, particularly in the United States, they are rare, and are 
not to be considered as consequences to be so regulai-ly expected, as in the 
phlegmasi?e. 

4. Inflammatory diseases are less subject to the intermittent form : The chill 
at the beginning is shorter and more rarely appears in the course of tlie disease 
than in general fevers. 

5. They are confined to no climate of the globe; some, however, as those 
of the lungs, pleurisy, pcripneumony, consumption and rheumatism are found 
only in cold; others, as hepatitis, more generally in hot countries. 

6. Like fevers, they are influenced by temperament of body, by tlie 
atmosphere, by plethora, by habits of life, by tlie state of the mind, &c. ; but 
contagion has little to do with their propagation: they do not at first arise 
from it, with but few exceptions, and with regard to some of these it is-doubt- 
ful'whether even they arise from contagion: 

Thus, phrenzy, pleurisy, rheumatism, and some inflammations of the viscera 
are not even suspected of originating in this manner, though ophthalmia, dysen- 
tery and pulmonary consumption, as tliey are seated in surfaces secreting mu- 
cus, have been supposed to be communicated by it, by the highest authorities 
in medicine. 

7. The tendency of inflammatory diseases to a crisis or to health ismucli less 
than in common remittent fevers of ordinary intensity; thus, pleurisies end in 
suppuration, rlicumatism becomes chronic, phrenitis ends in cflusion, in abscess, 
gangrene of the brain or death, from tlie violence of the action; whereas in 
common fevers nature may do all and the physician sometimes nothing, and the 
sick recover. 

In treating them, a professor of the expectant system of medicine can be tole- 
rated, and will receive patronage; in inflammatory diseases, that system would 
kill the patient and tlisgracc the physician: The means in inflammatory diseases 
must be well appointed, udministercd with energy and promptitude; if they arc 
not, deatli or a miserable protracted existence are often the consequences. 

It is true, that remittents sometimes exhibit great mortality, as in the ])laguc 
and yellow fever; the same, also, is true sometimes of inflammatory diseases; 
we hear of pleurisies in very cold seasons, and of inflammations of the liver in hot 
climates, which are almost beyond the control of medicine; in these cases the 
morbific causes have been ajjplied in the highest intensity; but as a general 
rule, in consec[uence of the local inflammations .attending the phlegmasix end- 
ing in suppuration, gangrene, xdccration, efl'usion, he. which in > itul org'tms 
arc necessarily fatal, remittents are more likely to end in recovery, bcr:uisc tliey 
have not so generally these local termin:itions. These, however, are onlygeny- 
ral positions', liublc to in: varied by m:iny cxce])tions: Thus, the phlegmasi;c 
are often by the occurrence of hot weather i-endcrcd bilious, and remittents in 
the autunm, on the aj)pc'ai-ancc of cold weather, become pleuritic, rheumatic, 
Sic. so that their tciideiuv to a crisis or rccoverv will be influenced by tliese 



OF INFLAMMATION. 281 

circumstances, according' as the one or the otlier preponderates. The general 
principles laid down by the author on the subject of fever will here t>hrow lig-ht 
upon the subject; and a proper consideration of the causes which influence the 
type will assist in determining- the judgment. 

8. In the phleg-masipe, the local affection is considered in tlie treatment, as the 
prominent evil to be overcome; in idiopathic fevers, the fever is the principal: 
thus, in pleurisy, we bleed till the pain in the side disappears, regarding vene- 
section as the polar star of our course; in fever, as for instance, in intermit- 
tents combined with apoplexy or coma, the disease must be cured through the 
fever, for wliich the bark is the remedy; for large bleedings increase, by the 
debility they produce, the tendency to the return of the fever; it must, how- 
ever, be used, but with caution in this complication; M-hereas, if apoplexy or 
coma, with high arterial action, proceed from any other cause, the most copious 
venesection, uncontrolled by any collateral consideration, must be practised 
as indispensable. 

9. The phlegmasiae do not admit of the apphcation of cold to the Burface, 
as idiopathic fevers; thoug'h the tempemture of tlie room must be reduced, 
yet, as they are often produced by cold, the affusion of water is not practised 
in these diseases. 

10. Bleeding is the principal remedy in these affections; and its quantity is 
regulated by the hardness of the pulse and the disappearance of pain from the 
partinflamed; it can be drawn in greater quantities than in common fevers, be- 
cause simple debility, and not typhus, as in fever, is the result of excessive de- 
pletion in this mode. 

Sometimes the violence of the inflammation will produce gangrene, in a few 
hours; blood must then be abstracted at once, and in great quantities; and if the 
pulse from the first be low and weak, it furnishes no objection to bleeding, 
more particularly if the inflammation be seated in the brain, the heart, the 
stomach, or intestines. These remarks, however, apply to persons in full 
health; to those who are weak, though bleeding is still the principal remedy, 
yet it must be taken in small quantities, and drawn locally. 

11. With reg-ard to the use of the other evacuations of emetics and purga- 
tives it may be observed, in certain inflammations, as that of the brain, emetics 
are not to be used, from the danger of producing apoplexy; purgatives, on the 
contrary, in that affection, by unloading the vessels, deplete most successfully 
that part of the system. 

In infiamniation of the lungs, fauces, and in the different species of cynan- 
che, emetics are useful; in that of the trachea, indispensable; In general, 
where they are proper they may be given in nauseating doses, so as to debilitate 
the arteries effectually, and keep them in that state till the secretions are fairly 
restored, when the blood-vessels come down to their natural state; for this 
purpose, small doses of calomel, followed by some resinous purgative, as advi- 
sed below, are very useful. In inflammation of the stomach emetics are danger- 
ous.and inadmissible in all cases; of tlie bowels, liver, bladder, from the agita- 
tion they produce, they are also hurtful: When they excite only nausea they 
may, by debilitating the sanguiferous system, be useful in the tlrree last ca- 
ses. Purgatives are beneficiul in all the phlegmasise; even to unload the bowels 
by mild diluents of a cathartic tendency in enteritis would be valuable, where 
the active purgative of jalap, &c. might be dangerous: Venesection must be 
our sheet anchor here : Sometimes it is combined successfully with opium in 
tliis variety : of this, more will be said hereafter. In general, in other inflam- 
mations, calomel at night, followed by senna and salts, or calomel and jalap, 
given in the dose of 10 grs. of each, so as to excite the secretions of the liver 
and skin by the former, and evacuate the bowels by the latter, has a fine ef- 
fect; the withdrawal of the blood to the bowels from the inflamed part bj'the 
irritation of the purge, and the evacuation of fluid from the surfiice of the intes- 
tines, depletes in the most decided and beneficial manner: Astlcy Cooper re- 
commends to fulfil these indications, one grain of calomel, with four of cathar- 
tic extract; or two g;i-s. of blue pill, with three of compound extract of colo- 

36 



282 (lENEllAL DGCTRJNE 

cynth; or infusion of senna with sulphate of magnesia: In children, he recom- 
mends calomel and rhubarb, glysters and the warm bath. 

12. By keeping- the bowels free by the above plan, the sudorific effect of me- 
dicine can easily be securedi Six giniins of tartar emetic dissolved in a quart 
of water, and given in tlie dose of a wine glass full every two hours is an ex- 
cellent sudorific: It vomits, given in the same dose every ten or fifteen mi- 
nutes, and it purges when g-iven every hour. Combined with calomel in the 
dose of four or five g-rains at night^ followed by this solution next day, or after 
the calomel operates, it has an excellent effect: The compound powder of ipe- 
cacuanha is also valuable: The warm bath or pediluvium assists the operation: 
The Dover's powder with calomel often quiets the irritable, hard, jumping 
pulsation of the arteries after bleeding and aperients.* 

With regard to the usual means of controlling the blood-vessels, we proceed 
to make a few remarks: 

The local means are cupping glasses or leeches, promoting the flow of 
blood by the appUcation of cloths wrung out of warm water; Leeches can be 
applied when the parts, whether internal or external, are so painful, that cups 
cannot be borne. The cupping glasses are often appUed without scarifying 
the skin; they divert the blood from internal parts in a state of inflammation; 
a common tea cup, or tumbler answers very well: The copiousness of the dis- 
charge of blood, after applying leeches, is an objection to their use, as also 
the uncertainty of the quantity lost: A little hnt applied on the surface will ge- 
nerally be sufficient to arrest any flow of blood: The inflammation if seated in 
the head may be abated by bleeding from the tempond artery or the jugular 
vein, or finally from the arm; It should be continued till the vis a tergo is much 
diminished, and in order to effect tliis it is necessary to take it rapidly, and 
in an erect position, as syncope then takes place more suddenly, and the 
inflammation is often completely suspended: It may be repeated and com- 
bined with local bleeding, if tlie case require it; Parts essential to fife, of 
course demand a more energetic treatment. Witli regard to the time, &c. 
quantity to be taken, &c., the directions given in p. 92. et seq. should be at- 
tended to. In general 20 oz. will be enough for a first bleeding in a stout and 
strong man; at the second, less. 

The hardness and tensity of the pulse, and not its frequency, furnish the in- 
dications for bleeding in the phlegmasia;; the hardest pulse is that, which oc- 
curs in inflammation of the heart; in that of the brain, next; hi that of the sto- 
mach and intestmes, it is so small as scarcely to be discernible. This is subject 
to great exceptions. The oppressed pidse often occurs in both: The same, it is 
stated, has also been observed in peritoneal inflammation: Quickness of pulse is 
& sign of irritabihty, which will be increased by bleeding; tlierefore, tliis sign 
alone in inflammatory diseases is not sufficient to justify bleeding; witli luu-d- 
ness, it is: On the subject of the buft'y and cupped state of the blood. Cooper 
states he found it in a case of scurvy; it, thoretore, is not always a sign of the 
necessity of bleeding. -[■ 

If the inflammation is merely local, of course such extensive depletion will 
not be necessary. If tlie inflanmiation is kept up by extraneous irrit;ition it 
will be necessary to remove the foreign body; tlien the above depletion will 
be more eflcctual: clysters of tobacco m:iy be used witli success to lessen 
arterial action : they openite by producing gre:it weakness. A half a pint of 
boiling water to 3 i- of tobacco is the pro})er ])roportion. Dr. Parry of liatli 
has proposed to cure inflanmiation by suppressmgthe flow of blood by pressure 
on tlie arteries going to a part: and he tliinks he h:is succeeded in lessening it 
by this means. InHanniution on the s:mie priucii)le when it occurs in the 
larger joints has been cured by tying up the ])rincipal artery going to the limb; 
This plan was proposed by Dr. Mott of New York; and Dr. Rogers of Uiat city 
has succeeded in curing a case of inflammation of tlie knee joint by it. ('. 

• A. Cooper's Lectures, vol. i. p. 69. Lond. 1827. 
\ A. Cooper's Lectures, p. (iO-l. vol. i. Lond. ia24. 



< OF INFLAMMAIIUN. :83 

1. When suppuration is established, moderate evacuations 

may sometimes be proper, and even rendered necessary by the 
urgency of a particular symptom; but tlie mischief being now- 
done, the object of the practitioner is rather to support the 
strength of the patient, than to risk, by further depletion, its 
complete exhaustion. A nourishing diet, therefore, and tonic 
medicines will often be requisite, in conjunction with such means 
as diminish local action, and lessen the quantity of purulent se- 
cretion. Internal gangrene being so rarely an object of treat- 
ment by the physician, it is only necessary to remark in this 
place, that it requires the exhibition of wine and other cordials. 
For the treatment of external gangrene, and for the treatment of 
external inflammation generally, I must refer to works on surge- 
ry, where this subject is fully treated; it being the most impor- 
tant of all those which occupy the attention of the surgeon. 

2. The treatment of internal inflammation is to be regulated, 
in some degree, by a consideration of the habit of body in which 
it occurs. Entonic inflammation demands blood-letting from 
the general system, full purging, and active measures of deple- 
tion. Inflammation occurring in weakened habits is, in many 
cases, more efiectually relieved by the /oc<2/ abstraction of blood, 
by blisters and such other means as lessen the action of the part, 
without impairing that strength of the general system which is 
so indispensable for the repair of injury. 

3. The treatment of internal inflammation is modified in the 
third place by the nature of the exciting cause. Scrofulous in- 
flammation of the absorbent glands, and inflammation of the 
periosteum or fauces from the venereal virus, require a peculiar 
treatment, adapted to the circumstances of each case. Tonics in 
the one, and mercury in the other, must be superadded to the 
general system of management already alluded to. 

4. To a certain degree, the structure of the part inflamed af- 
fects the treatment. Inflammation of a serous membrane de- 
mands the copious and rapid abstraction of blood. That of mu- 
cous membrane does not bear the same extent of evacuation, nor 
does it so often require it. Erysipelatous inflammation is often 
successfully treated by bark and acids. Rheumatic inflammation 
is under the control of certain drugs, which have comparatively 
but little efiect upon common inflammation; colchicum, for in- 
stance, mercury, and opium. 

The convalescence from all the severer kinds of inflammation, 
such as inflammation of the brain, lungs, larynx, or bowels, is 
very tedious, being often protracted for three or four months, 
and this, whether bleeding has been largely or sparingly em- 
ployed. The system receives a sliock from the occurrence of in- 
flammation in any organ necessary. to life, from which it reco- 
vers with great diiiiculty; nor does it appear that these subsc- 



284 GENERAL DOCTRINE OF INFLAMMATION. 

quent efforts of nature can be at all assisted (as in the case of 
fever) by the employment of bitter or other tonic remedies. 

Such are the general outlines of the management of acute in- 
flammation, under its several modifications. The subject is as 
important as it is extensive; for in inflammatory diseases the va- 
lue of medical treatment is more unequivocally manifested than 
in any other class of disorders, and the skill and resources of the 
physician are here put to their severest trial. 



( ^«o ) 



CHAPTER III. 

CHRONIC INFLAMMATION. 



Diversity of Structures affected by Chronic Inflammation. — 
Chronic Inflammation^ primary and secondary. — State of 
the Constitution in this j1 flection. — Causes of primary 
Chronic Inflammation. — Its Nature and Seat. — Effects of 
Chronic Inflammation. — Thickening of Structure, Schir- 
rus, Tumo7's, and Tubercle. — Chronic Suppuration. — Pre- 
vention and Treatment of Chronic Inflammation. 

Chronic inflammation is a term frequently made use of; but 
I am not acquainted with any work in our language which may 
serve to point out the pathological considerations which it in- 
volves. On this account, though the subject is perhaps too ob- 
scure for investigation in an elementary work, I have thought it 
advisable to offer a few remarks concerning it; rather, indeed, 
with the idea of attracting the attention, than of satisfying the in- 
quiries of the student. 

DIVERSITY OF STRUCTURES AFFECTED BY CHRONIC INFLAMMA- 
TION. 

Chronic inflammation occurs frequently, and in almost every 
variety of structure: in the lungs, where it lays the foundation 
of consumption; in the brain, liver, spleen, and kidney. All the 
serous and mucous membranes of the body are subject to it; and 
in many cases this proves a most formidable affection, as in chro- 
nic dysentery, and cafarrhus senilis. The substance of muscle, 
and the different species of fibrous membrane, appear to be the 
seat of chronic inflammation in some forms of rheumatism. The 
skin is of all textures the least liable to chronic inflammation, un- 
less, indeed, with some pathologists, we place in this class, lepra, 
psoriasis, and other varieties of chronic cutaneous disease. The 
same affection falls also within the observation of the surgeon. 
Gleet, inflammation of the prostate gland, scrofulous enlarge- 
ments of absorbent glands, chronic ophthalmia, and oza^na (or the 
chronic inflammation and ulceration of the Schneiderian mem • 
brane), may be taken as instances. 



286 CHRONIC INFLAMMATION. 



PRIMARY AND SECONDARY. 



Chronic inflammation is sometimes a pVimary, and at other 
times a secondary affection; that is to say, it succeeds acute in- 
flammation; and this is the most common form in which it ap- 
pears, witness gleet and dysentery. In other cases it begins al- 
most imperceptibly, and its advances are slow, often exceedingly 
insidious, being unaccompanied by any symptoms which could 
betray, even to the experienced practitioner, the existence of 
such a disease. Nowhere is this better exemplified than in some 
forms of chronic peritona^al inflammation; but the same thing 
has been observed also in cases of chronic inflammation of the 
membranes of the brain, and even of the heart itself. In these 
instances, not only are there wanting all local symptoms of in- 
flammatory action, but there are not even any constitutional 
symptoms; at least none of sufficient importance to attract atten- 
tion. This, however, is rare; and chronic inflammation, both 
primary and secondary, exhibits for the most part local and con- 
stitutional symptoms, less indeed in degree, but the same in kind, 
with those which accompany acute inflammation. These vary, 
of course, with the part affected. Sometimes, as in chronic la- 
ryngitis, there are local symptoms, but no sensible affection of 
the constitution. When the general system is implicated, the 
symptoms are usually those of fever. The pulse is quickened; 
there is a white tongue, thirst, and some degree of restlessness. 
Occasionally, however, in a state of chronic inflammation, the 
tongue is clean, there is no thirst, but the pulse is feeble and lan- 
guid, the extremities are cold, and the slightest exertion occasions 
fatigue, general uneasiness, and pain across the loins. All these 
symptoms mark' a state, not of fever, but of atony and debility. 
The term asthenia has been applied with much propriety, by 
some pathologists, to express this state of the general system. 
Many of the protracted cases of bronchial inflammation, particu- 
larly those which occur in old people, exhibit, in the greatest 
perfection, the characters of asthenic injlammation. 

CAUSES OP PRIMARY CHRONIC INFLAMMATION. 

The causes of /7nw«ry chronic inflammation are involved in 
great obscurity. There is reason to suspect that cold has some- 
times induced it; or the long continuance of some mechanical ir- 
ritation, as in the case of chronic inflammation of the brain, from 
spicula of bone; but it is seldom that we can attribute the disease 
to so obvious a cause. A scrofulous habit of body appears 1o fa- 
vour the disposition to chronic inflammation, but it often occurs 
where it would be mere hypothesis to attiibute it even to that 
obscure source. 



CIinONlO INFLAMMATION. 287 



NATURE AND SEAT. 

The nature of that action of vessels in which chronic inflammation 
consists, has heen long an ohject of research. By some, it has been 
defined to be that state of increased action of ^*essels, which is 
neither so far subdued as to tend to resolution, nor so violent as 
to form abscess; but this goes only a little way in explaining the 
difiiculty. From the appearance of the eye in some cases of 
chronic ophthalmia, and from the effects of ihcjuvantia and Ise^ 
dentia in this and many other instances of chronic inflammation, 
it would seem probable that a relaxation of vessels prevails, 
rather than any increase of their action. It must be confessed, 
iiowever, that this object of inquiry is obscure; and perhaps the 
truth, if it could be obtained, of no practical application. In 
France, a doctrine obtains, that chronic inflammation has its seat 
in two distinct orders of vessels, sanguiferous and lymphatic 
capillaries; but as this piece of pathology has never been re- 
ceived in this country, it will not be necessary to inquire into its 
merits. 

EFFECTS OF CHRONIC INFLAMMATION. 

The effects of chronic inflammation vary with the texture of 
the part affected. A simple thickening of structure is a common 
appearance, both in serous, mucous, and cellular membranes. 
Sometimes the thickening assumes the form which has been 
called tuberculated accretion. At other times the part inflamed 
is converted into cartilage and bone. Instances of ossific depo- 
sition taking place in consequence of chronic inflammation occur 
in chronic laryngitis, chronic pleurisy, and chronic pericarditis. 
A further effect of chronic inflammation (confined however to 
serous membranes) is the extensive union of opposite surfaces. 
Scirrhus is generally accounted the effect of chronic inflamma- 
tion in a glandular organ. 

The origin of tumours in different structures, is a subject that 
has excited much attention among pathologists. In many cases 
it is presumed that their growth is referable to the same action 
of vessels by which all parts of the body are formed; but in other 
cases, there is reason to believe that they may have had their 
origin in a state of chronic inflammation of vessels. Closely 
allied to tumours are tubercles; but the views which are enter- 
tained by pathologists of the origin and nature of tubercle, will 
come better under discussion hereafter, when treating of pulmo- 
nary consumption. 

The last effect of chronic inflammation which I shall notice is 
suppuration, ^d^ndi it is one of those which we have most frequent 
occasion to witness in practice. The fact of the formation of 



238 CHRONIC INFLAMMATION. 

purulent matter in cysts and other structures, without any evi= 
dences of previous inflammation, was well known to John Hun- 
ter, who had particular views of his own regarding it. But they 
are very unsatisfactory; and until further light is thrown upon 
ihe subject, it may not be improper to consider these collections 
of matter as the result of chronic inflammation. 

To some, the subjects which have now been discussed may 
appear too indefinite and obscure to be legitimate objects of in- 
vestigation, particularly in an elementary work. To this I 
would reply, in the energetic language of Bichat,* *Uhat in ex- 
plaining the animal oeconomy, it is doing much to indicate ana- 
logies; to show the uniformity of an unknown phenomenon with 
another about which all the world are agreed.'* " In every 
branch of science," adds this author, *^it would be well if the 
principle was thoroughly appreciated — that nature, greedy of 
her means, is prodigal of results; that a small number of causes 
everywhere preside over a multitude of eSects, and that the greater 
part of those about which we are doubtful, are referable to the 
same principles with others which appear to us evident.'' 

TREATMENT. 

The treatment of chronic inflammation is very little under- 
stood. It is often said, that parts which have been much weak- 
ened, especially by large bleeding during the acute stage, are 
liable afterwards to fall into the state of clironic inflammation. 
The remark, however, is not of general application, and this form 
of disease is oftener attributable to a neglect of those vigorous 
measures which would have cut short the acute stage of inflam- 
mation at its commencement. Chronic inflammation is almost 
as much out of the control of medicine as acute inflammation is 
under it. Nature sometimes works a cure; but in many cases, 
more particularly of primary chronic inflammation, nothing is 
found cflcctual in checking the disease. The general system of 
treatment must depend uj)on the state of the constitution. Four 
plans of treatment have been advised, and each has been found 
serviceable under diflerent circumstances. 

1. Where fever is present, blood-letting, purging, and saline 
medicines, with a low diet, are *') be recommended. 

2. Where the pulse is feeble, and there is a decided loss of 
tone in the system, myrrh, benzoin, the balsam of copaiba, steel, 
and bark, are unquestionably useful. 

3. Where the disease is purely local, it is best treated by 
loeches, blisters, and issues, upon the principlo of counter-irri- 
tation. 



Trsutc? fU\s Mcnihnuics, jiag'C 189. 



CHRONIC IXFLAMMATION, 289 

4. Where these means fail, an alterative j)lan of treatment 
may be resorted to. This is done under the idea of giving a 
new action to the vessels. Upon this principle mercury is em- 
ployed in the treatment of chronic hepatitis, alkalies in the scro- 
fulous inflammation of absorbent glands, and sarsaparilla and 
guiacum in chronic rheumatism. 

The plan of treating" chronic Inflammations by a slow and gradual action on 
the secretions, deserves more particular consideration tlian any other. Sir Ast- 
ley Cooper considers, that in chronic diseases some of the secretions are sup- 
pressed, and upon their restoration de])ends our success: Whether the reap- 
pearance of the secretions is the cause or the effect of the cure, it is difficult 
to say. In chronic inflammation, he advises calomel and opium; the pilul. hy- 
drargyr. comp. has in his opinion a more general action on the liver, intestines, 
and skin; and if the secretion of these org-ans be restored the local disease will 
disappear. This practice, which is nothing" more nor less than the mercurial, 
so strenuously and g"enerally recommended in tliis country, and more particu- 
larly by that excellent and great man, Dr. Rush, deserves to stand pre-emi- 
nent in all the curative processes in these diseases; it is however, particularly 
strengthened by the experience and practice of such a man as Sir Astley Cooper, 
as his attention has been confined more to diseases of a local bearing upon the 
system. Confirmed thus by ample experience, drawn from local and general 
sources, it cannot be too much prized: The forms in which it is given by Sir 
Astley Cooper are the ox}TTiuriate of mercury, dissolved in nitrous ether, and 
combined with the tincture of bark or rhubarb or sarsaparilla, taking care that 
the mercury be not given to excess, as it tends to increase rather than diminish 
irritability: In children. Sir Astley recommends, in chronic diseases, the hy- 
drarg}T. cum creta and rhubarb, or one grain of the oxjTnuriate of mercury 
dissolved in an oz. of tincture of bark, and given in doses of from half a drachm 
to one drachm, twice a day, in water, according to the age of the patient: Ca- 
lomel and rhubarb and the hydrargyrus cum creta and soda, are also considered 
as medicines of much value in the chronic disease of children: 

If mercury be not advisable, rhubarb and carbonate of soda, or rhubarb, soda 
and columbo, given often, and in small doses, he recommends very much; 
they operate as aperients, improve the digestion and appetite without exciting; 
great irritation. 



37 



( 590 7 



CHAPTER IV, 

LOCAL INFLAMMATION. 



Phlegmonous Inflammation — Treatmen t — Abscess — Morti- 
fication, from a high grade of action — Carbuncle or 
Anthrax — Treatment — General Remarks on the Treat- 
ment of Mortification — Mortification from defect of 
Action — Treatment — Mortification from Cold — Hospital 
Gangrene — Treatment — Burns — Treatment — Chilblains 
— Treatment — Cancer or Scirrhus — Treatment — Scirr- 
husin the Testicle — of the Prostate Gland — Cancer of the 
lips, nose, ^'C, with their treatment — Paronychia — Pe- 
riostitis — Inflamed Breast — Dentition. 

PHLEGMONOUS INFLAMMATION. 

This variety may be produced by any chemical or mechanical irritation, 
wounding-, contusing' or destroying' the skin or cellular membrane, in which it 
is seated; increased action of the blood-vessels, as in plethora, is also a cause of 
it: The most common form is the boil, which is a conical, pointed, circumscribed 
red swelling', with heat and pain, and a whitisli or livid pustule on the top, 
which is very sensible: It involves the skin and cellular membrane, and ends in 
the formation of pus, which is g'cnerally mixed with blood, is small in quantity, 
and seldom healthy: It is contained in a small cavity, formed by the agg-Iutinii- 
tion of the plates of the cellular substance, when it is seated as low as that 
memlirane; and which gradually tends to the surfice and is discharg'ed by a 
small opcnint^. 

Boils appear most commonly in children or young- people, in whom they are 
sometimes attended with loss of appetite, spasms, and fever; they follow the 
small pox, or take place on the surfaces where blisters have been applied, and 
then evince an inflammatory state of the system, which may occur even in a 
debilitated state, and require the use of very active means to relieve them : 
This frequently happens after small-pox, in which tlic continued use of mild but 
g-entle cathartics is required to subdue tiiis affection: 

They are attended with fever when they are numerous, and more particular- 
ly when seated on the l)uttocks or in the arm pits, w here they g-row to a con- 
siderable size; In healthy and strong- people, bolls are regarded as of no conse- 
quence; but, as they vary in degree, from the niost insig-nillcant pustule lo the 
most malignant carbuncle, it is of Importance to notice them partieuUu-ly; and 
as the same kind of inflanunation, both in progress and result, takes place on 
the injuries occ:isioned by both mechanical antl chemic;d irritants, as bullets, 
splinters, caustics. Sec. it is neccss:u-} to consider jiartieulaily the qualities of 
system which they evolve. 

Wh<*n matter is formed in a jihleg-mon, which has been so larg'C as to affect 
the system with fever, the throl)l)ing' pain in the tumor ceases; a constant numb 
coldness and weight of the part 1:ikes the i)l:ice of the p:un, and the swelling- 



LOCAL LXFLAMMATIOX. 291 

instead of being tense is attejided with fluctuation, on applyuij; tiic fingers to 
it, slicwing- the presence of mutter below; where the parts are soft, as in the 
abdomen, even though tljcy should he deep seated, the existence of an abscess 
can be determined by a skilful touch; the symptoms of chills, night sweats, 
&c. are the most certiiin indications of the formation of matter, w I icre the Hue- 
tuation cannot be felt: 

In general, however, the tumor is smafi, does not aflect the system with fe- 
ver, and the suppuration is seldom complete, being generally mixctl with 
blood and surrounded by a substance of a sloughy nature, which jnust be 
thrown olF before the part hcids up : The boil is airencystcd tumor, and thtt bag 
contauiing the matter must be discharged before the part w ill heal. 

TREATMENT. 

With regard to its treatment, I have seen a leech ajiplied in the forming- 
stage, completely airest it; and I have no doubt that by a suflicient numlier, as 
five or six, applied on tlie part, even when pretty far advanced and before the 
sac and the matter arc formed completely, the disease might be generally stop- 
ped. 

Cold succeeds sometimes in resolving local inflammation; one of the best lo- 
tions for producing it is an oz. of rectified spirits of w ine and five ounces of 
water, as I'ccommended by Astley Cooper. It should be a])plied by hue linen 
laid over the part, so that the evaporation may go on with facility: 

Ice apphed to the inflamed surface also answers well; it should not be 
permitted to touch it, as it irritates and is apt to produce gangi-cne.* The fol- 
lowing applications also may be used for this purpose; linen dipped in a solu- 
tion of sugar of lead, ^ii. to the pint of water; or in ^^ss of nmriate of ammo- 
nia, a gill of vinegar and as much water; or in the liquor of acetate of ammonia 
^ii. and brandy four ounces; or in camphorated spirits ^i., vinegar ^iii., and 
sugar of lead _^i.; or in a simple solution of vinegar and salt, applied to it, and 
frequently renewed: Simple cold water, a solution of nitre, applied by linen 
cloths, or ether dropped upon the part, will also have a tendency to airest its 
progress : 

Some interesting facts arc recorded on the subject of the prevention of sup- 
puration, by the ai)plication of ice to an extensive wound of the brain and dura 
mater, and in a compound fracture of the leg, occiu-ring in the practice of Drs. 
Johnson and Harrison, of Louisville :f Though the dura mater was extensively 
wounded, the process of healing went on in the most favourable manner, the 
undue action being kept down, preventing, it is probable, hernia cerebri in the 
wound of the brain, tdl the patient completely recovered. 

An indolent hardness often remains behind, when it is resolved, and prevents 
a cure; for it frequently suppurates several times before this hardness is remo- 
ved, which at last is effected by a free discharge of the matter. 

When a boil appears on the face, to prevent the scar, it is important to dis- 
cuss it: The above mentioned means are proper for this purpose, as also gene- 
ral bleeding, (which of course can only be advisable when the boil is large,) a 
low diet of whey and vegetables, without meat, fish or flesh of any kind, 
butter or eggs: 

If there be fever, nitre in the dose of 15 grs. with one-sixth of a grain of 
tartar emetic in two table spoonfuls of water are to be taken every hour, or 
spiritus mindereri 5i. with the one-eighth of a grain of tartrite of antimony, or 
the salt of tartar ^i. taken in two tea spoonfuls of lemon juice or a table spoon- 
fid of vinegar in an eftervescent state, and repeated every hour, promoting the 
perspiration at the same time by vinegar wliey: The Dover's powder an- 
swers also a very good purpose: This depicting plan is more particuhu-ly 



" A.Cooper's Lectures, vol. i. p. 78. Lond. 1824. 

t Fliil. Mouth. Journal of Mcdicuie and Surgery, for 1828. 



292 LOCAL L\FLA>.L>L\1U)N. 

valuable, when tiic suppuration threatens to be extensive and the inflammation 
runs high; the matter is al\va)^s more healthy, if resolution cannot be effected, 
when the g-eneral action of the system is kept down. 

The following- applications, honey strong-ly acidulated with sulphuric acid, 
camphorated oil and alcohol, are also recommended, to promote resolution; 
they cannot be made after the leeches are apphed, because they would irritate 
and inflame the tumor, and thus promote the suppuration. 

When.suppuration is inevitable, a bread and milk or linseed poultice, covered 
with lard, should be applied; a linseed poultice is made by pouring" a pint and 
alialf of warm water upon half a pound of linseed, till it becomes of the pro- 
per consistence, and adding- a small quantity of sweet oil, to prevent it from 
hardening-; A poultice of yest and oatmeal, or vinegar and oatmeal, is also 
recommended: Sir Astley Cooper recommends the poultice to be wet with a 
solution of a table spoonful of common salt to the pint of water, a^ the best 
applicaion for promoting suppuration: If the suppuration is slow, from general 
debility,acompound plaster of galbanum, the emplast. thuris composit; adhesive 
plaster, the emplast. amnion, cum. hydi-argyr; a poultice of onions, of garlic, 
or the soap cerate, may be used; the plasters just mentioned are more conve- 
uient, as they permit people to attend to tlieir business: 

Where the suppuration is slow, and evidently from the general system being 
below par, ammonia, bark, wine, a diet of mutton, beef and fowls, without 
gravies, pastry, or any indigestible food, should be given to support the action 
of the heart and arteries: 

As soon as the tumor jjoints sufficiently open it with a lancet, feel and press 
out the sloughs; and as soon as it begins to heal it should be dressed witli simple 
cerate or fresli hog's lard spread upon linen : Mercurial plaster spread upon 
leather and applied to the part, removes the remaining hardness: 

Sometimes, in debilitated subjects, after small-pox, measles, scrofula, lues 
venerea and other chronic diseases, indolent boils appear, which discharge a 
thin and badly maturated matter, an^^^vhich on being fairly opened, throw off 
many sloughs before healing; they aite treated in the same way as above, only 
ivith this difference, that g-entle cathartics must be administered,* in order to 
rid the system of the disposition to form these inflammations. 

TOOTH-ACHE. 

Tooth-ache is almost always owing to an inflammation produced by caries of 
the tooth; as it aggravates otlicr diseases and is ;dways very painful, it becomes 
necessary to know how to stop it: Dropping alcohol, brandy or laudanum into 
the ear of the affected side, docs it like a chai-m; also a few drops of oil of cloves 
applied to the hollow tooth by a small piece of cotton; the smoke of tobacco 
blown into the ear; a solution of alum in nitrous ether applied to the decayed 
surface of the tooth. These arc palliatives. Extraction is the only certain 
remedy. 

EAR-ACHE. 

Ear-ache generally proceeds from inflanmiation, and is common in children: 
Leeches near the car, a blister afterwards applied behind it, a poultice of onions 
put over it, or a clove of garlic put into it, will generally succeed in relieving 
it: Underwood describes it as sometimes sj)asnu)(lic; itthcn returns at mtervals, 
ceasing for a time between tlicm. He reconunends tiie juice of rue, ova little 
laudanum dropped into the car: 

ABSCESS. 

Abscesses may he divided into such as are formed rajiidly, and into those 
which are produced more slowly; the former has been called acute; the latter 

* Cooper. 



LOCAL INFLAMMA'I'lON. 293 

cliroiiic: ill tlie first, about eighteen or twenty days is required for tlie forma- 
tion of matter^ in the second or chronic, it may be months; as, in the psoas 

abscess: 

Acute abscesses are best treated by purgatives, to prevent costiveness; by 
opium, to keep down the pain and irritabihty, and sudorificsto lessen the gene- 
ral fever;* Epsom salts in small doses three or four times a day, as a tea spoon- 
ful; or six grs. of tartar emetic may be dissolved in a quart of water, and if the 
bowels are costive, a wine glassfuU may be given every two hours; if a sudo- 
rific is required, the same every four hours; and if the stomach is out of order, 
the same quantity every ten Of fifteen minutes will operate as an emetic. A 
table spoonful of the spiritus mindereri may be given with it, or tlie spirit, 
mind, alone may be taken, • 

Sometimes abscesses form after fevers in different parts of the body; it is 
necessary to determine their existence early, by feeling for them, and open 
them, either by an incision made directly into the abscess, or by a seton run 
through it-, the last mode has the advantage of discharging the matter slowly; 
excessive debility, from the inflammation of the sac, or fainting, from the rapid 
discharge of its contents, is thus avoided; the latter is sometimes followed by 
death, in low fevers: 

When an abscess forms of any considerable extent, it is proper to open it by 
drawing the skin to one side and keeping it in this situation, and then plunging 
in the lancet; keeping it open till a sufficient quantity is drawn off, to prevent 
debility: by letting go the skin the aperture is covered and the further dis- 
charge of the matter is prevented; or a flat trocar, with a canula concealed in 
it, may be run in below the skin, and then plungedinto the abscess, and thus 
the matter may be drawn off through the valvular incision, without endanger- 
ing the access of air to the cavity, which might, if emptied entirely, endanger 
life by inflaming its sides: The strength must be supported by a diet of mut- 
ton, beef and fowls, avoiding diluents, taking the bark or other bitters with 
wine, porter or brandy, as they may suit the system. In dressing the abscess, 
after opening it in this way, all that is necessary is to draw the edges of the 
wound close by adhesive plaster, to apply a compress wet with lead water over 
the wounded part, and surround it witli a roller; the skin heals up without 
leaving a scar; an abscess may be cured in a very short time in this manner, 
which, without it, would have endangered life, or occupied months in its resto- 
ration. This plan is practised, particularly, with regard to the abscess of tlie 
psoas muscle, in which, from the size of the collection of matter, the danger of 
inflammation of the sides of the cavity is particularly great. The state of the 
system is to be learnt, partly from the qualities of the healthy pus, which ai-e 
to be found in page 267, and also from the debility, the night sweats, &c. 

Abscesses become dangerous, if seated in vital parts, as on the surface or in 
the brain; a very small portion of matter on the surface of this organ will pro- 
duce death: in the heart, they are also dangerous; in the Uver, also, from the 
danger of their bursting internally; in the lungs, they often kill by suffocation, 
■when they burst: Abscesses in the pharynx, also often produce death by pres- 
sure on the glottis and epiglottis; also, when they form between the prostate 
gland and rectum; tliey obsti-uct the urethra, and the patient dies of suppres- 
sion of urine, f 

The size of abscesses, also, frequently makes them dangerous; the system 
is exhausted by the inflammation which comes on in their sides after opening 
them; or if tliis does not take place, the discharge of matter exhausts, and the 
cavity becomes so large, that the system cannot fill it up. 

Sometimes, the matter of an abscess is removed by absorption, the cavity 
gradually filling up by the formation on its sides of gi-anulations, which consist 
of the growth of blood-vessels, in the form of small red conical eminences; by 
their contraction they diminish the abscess, till at last it is completely obhtc- 
rated. 



* A, Cooper. 

t A. Cooper*s Lectures, vol. i, p. 14o-4. 



294 LOCAL INFLAMMATION. 

In general, common boils should not be opened, as they do not heal so readi- 
ly as when left to nature, particularly if punctured unnecessarily or prema- 
tiu-ely.* 

Wiien an abscess appears in the liver or any part of the abdomen, in the tho- 
rax, over the large joints, in the eye, under the cranium, under tlie fascire, the 
spreading- of the matter, or the destruction of the functions of important or- 
gans by its detention, of course, renders it expedient to let it out immediately: 
the penetration of matter into the cavities of the abdomen, tliorax, or of the 
larger joints, is often fatal. The same is tiiie of abscesses near a bone, except 
when they appear between the cranium and peiacranium from severe courees of 
mercurvi if unattended by any blush on the skin, they must not be opened; 
purging and sarsaparilla will then cui^ it; but if there is a blush on the skin, 
it must be opened, as exfoliation will take place.f 

Abscesses are best opened with the lancet or bistoury; the use of caustic is 
tedious, more unmanageable, more painful, and leaves a scar: It is entirely in- 
admissible in the face and neck of women: To prevent them, Astley Cooper 
gives the following directions; Keep the bowels open witli calomel and rhu- 
barb; apply evaporating lotions to the part; low, but nutritious diet; The ab- 
scess must be opened before the skin over it is much afiected; open the abscess 
with a knife the eighth of an inch wide; it appeal's like a needle to the patient; 
the openijig must be small; after opening it, all the solid flakes of matter found 
in the abscess must be squeezed out; if tliey are not removed, slougliingis the 
consequence, and if they are, adhesion will take place: 

The abscess must not be opened if it be of the colour of a grape, as it will 
certiiinly slough; The direction of the incision must be across the neck, so as 
to be concealed, if possible, by the creases or folds of the skin: if any part of 
the abscess does not heal, a small injection of sulphate of zinc or copper is 
recommended, t 

When caustic is used to open an abscess, it is applied by dipping the end of 
the caustic in water and rubbing it upon the part, previously covered with a 
piece of adhesive plaster,with a liole cut into it of the size of the intended eschar; 
When the skin becomes brown, we desist, the surface being washed oft' with 
some wet tow; tlie plaster is then removed, and a poultice of bread and milk or 
flaxseed meal applied over the part: 

Abscesses should be opened in their lowest part, to give a free vent to the 
matter; as the gTcatest pressure, from the weight of its contents, is there, of 
course the absorption is there more likely to take place, and the matter to es- 
cape more easily; besides, if the abscess be opened on the upper instead of its 
most depending part, the pressure of the matter upon the lowest part will be 
sufficient to prevent the formation of granulations to fill it up, and the abscess 
healing from the top downwards, will be more likely to form a fistula. 

When, however, the abscess happens in the foot, or on the inside of the 
mamma, and points on the upper parts of either, it would be absurd for the sake 
of opening it at its lower part, to cut through from the bottom upwards: the place 
of poin